(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Biodiversity Heritage Library | Children's Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "Hospitals and health agencies of San Francisco, 1923; a survey"

spitals and Health Agencies 

of 

San Francisco 
1923 

A SURVEY 



By 

HAVEN EMERSON, M. D. 

and 
ANNA C. PHILLIPS 



s 






Made for 
lie Committee on Hospitals and Health Agencies 

of the 
Council of Social and Health Agencies 

of 
San Francisco 




REGIONAL 

DEVELOPMENT 

LIBRARY 



803 PHELAN BUILDING 



SAN FRANCISCO 



TELEPHONE GARFIELD 3524 









ft 



IATIOST 



ty Counties 

|f CISCO 



c 



SANFR 



3^2.1 




TORY ROOM 



SAN FRANCISCO 
PUBLIC LIBRARY 



SAN FRANC SCO PUBLIC LIBRARY 



3 1223 90150 8474 



REFERENCE BOOK 



Not to be taken from the Library 



PROPERTY 

OF THE 

CiTY.PLANNI : COMMISSION 

'CITY AND COUNTY OF SAN FRANCISCO 



Hospitals and Health Agencies 

of ■ 

San Francisco 
1923 

A SURVEY 



By 

HAVEN EMERSON, M. D. 

and 
ANNA C. PHILLIPS 






Made for 
The Committee on Hospitals and Health Agencies 

of the 
Council of Social and Health Agencies 

of 
San Francisco 



COPYRIGHTED 
- BY 

The Community Chest 

of 

san francisco 

1923 






5. F. PUBLIC LIBRARY 



jl-U 



RE QIC 

of San x> Bay Counties 

SAN FRANCISCO 

Letter of Transmittal 



To the Committee on Hospitals and Health Agencies of the Council of 
Social Agencies of San Francisco, 

Sharon Building, San Francisco. 

Dear Sirs: 

The letter of your chairman, Dr. Ray Lyman Wilbur, of April 20th, 
1923, and subsequent communications from the general secretary of the 
Community Chest, Mr. H. J. Maginnity, made it clear that the objects 
of the Survey of Hospitals and Health Agencies which I was asked to 
undertake were : 

1. To learn the present status of the work, and relations to each 
other and to the community, of the various hospitals and health agencies 
of San Francisco. 

2. To prepare a program for safeguarding health and to provide 
for the sick, which would meet the needs of San Francisco and could be 
put into effect through the influence and resources bf the Community Chest. 

3. To outline the relations and share of responsibility of the hospitals 
and health agencies in such a scheme. 

4. To suggest a plan for future development which will provide for 
the growth of the population, not only in size but in the conception of 
services which the medical and social sciences recognize as essential to 
permit of the fullest safety and enjoyment of human life. 

On June 11th the study was begun, and the field work was completed 
on July 21st. The analysis of the data obtained and the preparation of the 
report have been under way since August 20th. Miss Anna C. Phillips 
has been associated with me, and responsible for most of the study of ad- 
ministration of hospitals, and for the organization and direction of the 
social and statistical studies of services for the sick. 

Even though you are doubtless aware of the extent to which the 
offices, resources in personnel and equipment, and the invaluable relations 
of the Council of Social Agencies and of the Community Chest, were put 
at our disposal, you cannot know the full measure of the patience, tact, 
industry and unselfish devotion to the public interest which we met through^ 
out our period of study in San Francisco, from all to whom we appealed 
for information, opinion and counsel, whether they were private citizens 
or representatives of public or private agencies or members of the press. 

A special acknowledgment is due to those who carried out the inquiry 
into the condition of patients recently discharged from hospital care. 
This study required of the field workers skill and experience in medical 
and social needs and resources, particularly among the sick poor. 



During the three weeks when the bulk of the field observations were 
made, there were twenty-one persons engaged on part or full time in the 
study, the equivalent of ten persons on full time, while much assistance of 
the regular staff of your offices was given to matters directly contributing 
to our work. 

The cost of the survey, including the preparation of the report, has 
been $5489.17. Printing of 1000 copies of the report as herewith pre- 
sented will cost approximately $700. 

Disregarding for the moment any possible benefits to accrue in the 
future from such a study, it is not too much to say that the economies 
suggested through the establishment of a central purchasing bureau, would 
within twelve months reimburse the Community Chest for its investment 
in the Survey. 

Expressed in terms of added cost of hospital administration this 
attempt at diagnosis or analysis of a community, as to its provisions for 
protection against diseases and services to the sick, would add $2.18 to 
the cost of maintaining each of the 2782 beds in the ten hospitals re- 
ported upon in detail, or a charge of a little more than one cent ($0,011) 
upon each member of the community in the year 1923. 

Please accept the report herewith submitted in compliance with your 
request and believe me, 

Respectfully yours, 

(Signed) Haven Emerson, M. D. 

October 27th, 1923. 
437 West 59th Street 
New York City 



REPORT OF THE SURVEY 



TABLE OF CONTENTS 

Page 

SECTION I— THE COMMUNITY OF SAN FRANCISCO IN 1923 1 

Area and Population 1 

Districts 2 

Vital Statistics 3 

Death Rates 4 

Birth and Infant Mortality Rates 4 

Maternal Risk Rate 5 

The General Situation 5 

SECTION II— SERVICES FOR HEALTH AND ITS PROTECTION.... 6 

Chapter 1. 

Department of Public Health 6 

Chapter 2. 

Problems in Health Service 9 

Health Education 9 

Tuberculosis 11 

Child Hygiene 15 

Mental Hygiene 17 

Venereal Diseases 21 

Heart Diseases 23 

Cancer 23 

Periodic Health Examinations 25 

Health Council 26 

SECTION III— SERVICES FOR THE SICK 27 

Hospital Provisions and Community Needs 27 

Chapter 1. 

Hospitals 32 

Organization and Administration 34 

Services Rendered by Hospitals 39 

(a) Extent of Use of Hospital Beds 40 

(b) Services to Patients of Different Economic Groups 47 

(c) Medical Services Maintained 54 

Inadequacies of Medical Services 60 

(d) Areas Served 66 

Hospital Finances 70 

Accounting Systems 73 

Hospital Rates 76 

Laboratory Charges ". 78 

Summary 79 

Hospital Council 80 

Chapter 2. 

Dispensaries 83 

Medical Services Provided 86 

Organization and Control 91 

Services Rendered by Dispensaries 92 

(a) Dispensary Attendance — 1922 92 

(b) New Dispensary Patients 98 

(c) Areas Served 99 



Page 

Dispensary Plants 102 

I dispensary Finances 103 

Chapter 3, 

I lospital Social Service 105 

( lhapter 4. 

Visiting Nurse Service 112 

Chapter 5. 

Com alescent Homes 118 

( Chapter 6. 

Monies for the Incurables and Chronically Sick 123 

SECTION IV— RECOMMENDATIONS 130 

Chapter 1. 

General Policies 130 

Chapter 2. -. 

Appropriations of Funds by the Community Chest 132 

1. Basis for 1924 Appropriations 133 

2. (a) Franklin Hospital . 133 

(b) University of California Hospital 134 

3. Lane and Stanford University Hospital 134 

4. Osteopathic Clinic 135 

5. French Hospital 135 

6. Mary's Help and St. Mary's Hospitals. 135 

7. Hospital Council 136 

8. Health Council 136 

9. Division of Child Hygiene ' 136 

10. Social Service Departments 136 

11. District or Visiting Nurse Association 137 

12. Convalescent Homes and Homes for Chronic Invalids........ 137 

Chapter 3. 

Progress in the Field of Public Health 138 

1. Health Education 138 

2. Child Hygiene 139 

3. Tuberculosis 141 

4. Mental Hygiene 141 

5. Venereal Diseases ..'...' 142 

6. Heart Diseases 143 

7. Cancer 143 

8. Periodic Health Examinations .« 144 

SECTION V— FORMS, LISTS, ETC 145 

Letters to Physicians 145 

Letter to Social Agencies 146 

Cleveland Hospital Council Report Form 147 

Convalescent Study Form 149 

Long-Term Patients in Hospitals . 150 



Survey of the Hospitals and Health Agencies 

of San Francisco 



SECTION I 

The Community of San Francisco in 1923 

For convenience of reference in understanding the discussion and the 
relative importance of many of the matters which follow, a brief descrip- 
tion of San Francisco so far as concerns the size, the area occupied, the 
economic status, age and race groups of the population, and the elementary 
facts of births, deaths and sickness, seems advisable. 

AREA AND POPULATION 

The land area of San Francisco, containing 46.5 square miles, or 
29,760 acres, was on July 1, 1923, occupied by 539,038 persons, according 
to estimates based upon the last enumeration by the Bureau of the Census 
as of January, 1920. This is equivalent to a density of 18 persons 
per acre for the entire area. Although there are other large cities of the 
country with less concentration of population per acre, 1 few if any are so 
free from districts or blocks where there is a dangerous density of popula- 
tion. 

The per capita property valuation of San Francisco, based on actual 
or 100 per cent value of real estate, improvements and personal property, 
is $2220 or a total of $1,196,580,000, higher than that of any city of over 
500,000 population except Chicago. 

Of the population under twenty years of age, which amounts to 
26.2 per cent of the entire community, there is an excess of males over 
females of about 2500. 2 

The four important groups under twenty are about equally represented : 

64.14 per 1000 of the population under 5 years of age 

66.25 " " " " " 5 to 9 

62.62 " " " " " 10 to 14 

68.49 '\ " " " " 15 to 19 



>y yy a 



There is obviously some error in the figures offered by the San 

1 Report of Committee on Municipal Health Department Practice. U. S. P. H. S. Bul- 
letin No. 136, July, 1923. 

2 Fourteenth Census of the United States, 1920, Vol. Ill, page 3. 



Hospital and Health Survey 



Francisco Board of Education for children from 5 to 14, owing partly 
to the fact that reports from private schools are not compulsory, partly 
to the incompleteness of teachers' class reports, and partly to the failure 
to take into account the 4 per cent to 6 per cent of children of these 
ages who should attend school but are generally not found or brought 
under school control. 

In January, 1 () 20, actual enumeration by the Federal Census Bureau 
showed there were in San Francisco, between the ages of 5 and 14 years, 
32,624 boys and 32,718 girls, a total of 65,342. 

In October, 1922, the San Francisco Board of Education reported 
55,952 hoys and girls of these ages, although since the time of the federal 
census of 1920 the city had gained 25,000 in population, of whom about 
3200 are estimated to be children between 5 and 14 years of age. It is 
probably safer to use the Federal Census Bureau figures than the reports 
of the Board of Education in this particular. 

DISTRICTS 

While the city has been arbitrarily divided into four districts for the 
convenience of administration of the functions of the Board of Health, 
the facts of population, births, deaths, sickness, etc., are not recorded so 
that analyses can be made of the relative safety of life, or in the matter 
of health liabilities and assets district by district. The experience of the 
city of New York in assembling all its vital records by so-called sanitary 
areas which correspond to multiples of the census enumeration districts, has 
been so valuable to the social, religious, medical and health agencies of the 
city that it can be confidently predicted that similar advantage would 
follow the adoption of a comparable area basis for San Francisco's human 
bookkeeping. 3 

Certainly, it is impossible to give that detailed epidemiological study 
to race, industrial and economic groups of the population, which is required 
by modern science when a city of 500,000 is considered as a unit rather 
than as a composite of numerous distinct areas or neighborhoods, each with 
its separate needs and resources, 

The four districts as defined in the operation of the Department of 
Public Health are not on an equalized area basis, and furthermore, com- 
parable and complete reports of births, deaths and sickness are not re- 
ceived or tabulated for all four districts. 

We must, therefore, picture the situation for the city as a whole, 
disregarding differences in birth, death and sickness ratios in different 
parts of the city, which probably vary as widely in San Francisco as in 
other cities. For instance, the tuberculosis mortality in the Riverside dis- 
trict of New York City is 50 per 100,000, while in the Bowling Green 
district it is 1171 per 100,000. Only by subdivision and analysis of the 



3 Statistical Sources for Demographic Studies of Greater New York, New York City 
1920 Census Committee. 



The Community of San Francisco in 1923 



population of a city upon a district, or permanent equalized area basis, can 
the need for and distribution of preventive and relief resources be clearly 
understood. 

VITAL STATISTICS 

The three features of the population of San Francisco which bear 
particularly upon the problems of health and sickness are, the considerable 
floating population, characteristic of great seaport cities, the colony of 
8000 Chinese within the city and about 5000 more in the bay region 
who look to San Francisco for medical relief and care, and the Italian 
colony in the Telegraph Hill region. Owing to the lack of district analysis 
of the city above referred to, and to the absence of hospital records which 
would make a study of sickness and deaths among the transient or non- 
resident population of San Francisco possible, further comment upon these 
particular features is impracticable. 

Among the large cities of the United States, San Francisco is notable 
for the relatively high proportion of native white stock among its popula- 
tion, the high standard of living, the extent of self-support, and the con- 
sequent self-respect and absence of widespread pauperism and degrada- 
tion which prevails among the recent immigrants from the South European 
countries, whose presence in large numbers and in congested tenement 
colonies has created such serious relief and medical problems in many of 
the eastern seacoast and industrial cities of the countrv: 

I. Population by Age Groups Per 1000 of Total Population for New York and 

San Francisco, 1920 



Total 

Population 

1920 



Number 
Under 

20 years 



New York 

5,610,048 2,045,984 

San Francisco 

506,676 132,591 



Ratio 
per 
1000 



364' 
262 



Number Ratio 

Between per 

20 and 40 1000 
years 



Number Ratio Number of Ratio 
Over per years per 

40 years 1000 Unknown 1000 



2,109,049 
204,750 



375 

404 



1,457,210 
166.444 



259 
328 



7,805 
2,891 



II. Per Cent of Populations of Native and Foreign Parentage 



Native Born Whites 
of Native Parentage 

New York Per Cent 
1,164,834 29.73 

San Francisco 

167,179 33.0 



Native Born of 
Foreign Parents 

Per Cent 
2,303,082 40.98 

182,643 36.0 



Foreign Born 
Whites 



1,991,547 



Per Cent 
35.44 



140,200 27.7 



Negro 

Per Cent 
2.71 

.5 



1 
6 



Other 
Colored 

Per Cent 
.14 

2.8 



III. White Population of San Francisco, 1920, by Foreign Parentage Groups 
(Native Born of Foreign Parents and Foreign-Born Whites) 



Ireland 63,299 

Germany 53,924 

Italy .45,599 

England 23,132 

Canada 12,619 

Russia 12,068 

France 11,806 

Sweden 11,407 

Austria . 9,983 

Scotland 8,592 

Denmark 6,278 

Norway 5,397 



Switzerland 5,298 

Mexico • 5,180 

Spain 4,208 

Greece 3,868 

Finland 2,711 

Hungary 2,591 

Portugal 2,141 

Central and South America.. 2,005 

Others under 2000 9,923 

Mixed Foreign Parentage. . . .20,814 



322,843 



I 



4 Hospital and Heai/th Survey 



Two further facts appear to be significant in the matter of population, 
the very low birth rate of the city and the high cancer death rate, which 
give evidence of an age grouping of the population with a higher propor- 
tion in the decades over forty than is the case in other cities with higher 
birth rates and lower cancer death rates. The situation can perhaps be'st 
be illustrated by the following summary for San Francisco and New York 
City: 

Rates per Thousand of the Population Per Cent of Popu- 
Birth Rate Cancer Death Rate lation over 40 

San Francisco 16.6 (June '22-May '23) . ...1.51 32.8 (1920) 

New York 23.2 (1921) 97 25.99(1920) 

DEATH RATES 

During the twelve months, June 1922 to May 1923 inclusive, there 
were 7149 deaths, giving a death rate of 13.26 per 1000 of the population, 
without correction for non-residence, race, sex, or age. San Francisco's 
general death rate would be considerably lower if it were corrected for 
the age groups of the population, according to standard statistical practice. 

The fluctuation in the general death rate from month to month is much 
less than is common in cities with a more rigorous climate and where wide 
changes of temperature distinguish the seasons. This is a fact of much 
importance as will be seen in studying the similar uniformity in use of 
hospitals throughout the year. The months of highest general death rates 
are January, February and March, due apparently mainly to the increase in 
deaths from pneumonia in these months, February and March showing 
also the high periods of hospital occupancy. While May and September 
show the least use of hospital beds, it is in June, July and August that 
the general death rate is lowest. (Chart B, page '45. ) 

More than half of the general death rate from all causes (6.78 per 
1000 of the population) is due to deaths from pneumonia (.57), all forms 
of tuberculosis (1), violence (1.12), cancer (1.51), and diseases of the 
heart (2.58). The very low typhoid fever death rate (.03) gives an ex- 
cellent index to the sanitary quality of water and milk supplies and the 
disposal of human waste. 

BIRTH AND INFANT MORTALITY RATES 

There were 8557 babies born in San Francisco in the twelve months 
Tune 1922 to May 1923, of whom 436 died before they were a year old, 
giving an infant mortality rate of 50.95 per 1000 living births. The infant 
mortality rate for 1922 (57), was lower than that of any city of 100,000 
population or over in the United States except Seattle (49), Minneapolis 
(53) and Portland, Oregon (56). 

The birth rate of San Francisco in 1922 was 16.6, lower than that 
of any of the larger cities of the country except Los Angeles (16.2). In 
the twelve months, June 1922 to May 1923, the birth rate was 15.8. 



The Community of San Francisco in 1923 



Of all the births reported, 10 per cent were by midwives and about 
65 per cent from hospitals. No other of the large cities of the country- 
shows so large a proportion of all maternity cases cared for in hospitals. 

MATERNAL RISK RATE 

In 1922 there were 8656 living births and 195 stillbirths reported, or 
a total of 8951 pregnancies. There were 60 deaths of mothers from 
causes connected with childbirth, giving a maternal risk rate of 67.03 per 
10,000 pregnancies. 

While this rate is not particularly high for cities in the United States, 
it is much higher than the maternal risk rate in several of the cities of 
England where rates of 38 are recorded. It is probable that the high 
maternal mortality is in large part due to the inadequate development of 
prenatal care of expectant mothers, only a small per cent of whom receive 
consistent medical supervision from the fourth month of pregnancy onward. 

THE GENERAL SITUATION 

We see San Francisco, then, as a city favorably located as to topog- 
raphy and climate for the maintenance of excellent sanitary standards of 
environment. 

With a protected water supply, and the assurance of adequate increase 
to meet the demands of the future, with an easy and safe provision for 
disposal of human waste, with few, if any, of the inconveniences or hazards 
of industry to handicap its citizens, San Francisco faces chiefly the health 
problems caused by the presence of various common communicable diseases, 
and the widespread unfamiliarity of its people with the means of self- 
protection and lacking information based on modern biological science, 
upon which the development of sturdy, vigorous bodies and the training 
of alert and well-balanced minds and nervous systems depend. 

Generosity and initiative, confidence and determination to succeed in 
providing health protection and care for the sick, have characterized San 
Francisco's accomplishments to date. 

From now on, concerted action, accurate analysis, keen imagination 
and long distance planning will probably be the notable features of the 
universal co-operation which has crystallized in the formation of the Com- 
munity Chest. 



SECTION II 

Services for Health and Its Protection 

While it can be fairly argued that all services for the sick contribute 
directly or remotely to the health of the community, there are sufficient 
differences in function between the agencies dealing primarily with health 
and its protection, and those which have been created for the diagnosis 
and treatment of disease, to justify separate consideration of them. 

For convenience of presentation we may best consider first the or- 
ganization and activities of the Board of Health and then discuss under 
functional headings other important services developed chiefly under 
separate auspices and in process of transfer to public authority. 

Chapter i 

THE DEPARTMENT OF PUBLIC HEALTH 

The method of appointment, the qualifications, and the terms of service 
of the members of the Board of Health meet the best standards of munici- 
pal practice. It is, however, not considered a wholly suitable situation 
which imposes upon the same directing body responsibility for the highly 
technical work of providing hospital care for the sick poor of the city and 
for the domiciliary care of the aged and infirm indigents, as well as for the 
development of the many types of medical and social resources which must 
be used for the protection and maintenance of health. As the city grows 
and the burden of these several services becomes unbearable, there will 
surely be needed a board of trustees for the San Francisco Hospital, with 
its special divisions for isolation, for tuberculosis and for leprosy, and its 
chain of four outlying emergency hospitals, the Relief Home, etc., which 
will bear the same relation to the superintendents of these institutions as the 
Board of Health does to the Health Officer. Progress in public health 
work in San Francisco would doubtless have been faster and have received 
more support if a great part of the time and energy of the Health Officer 
and of the Board of Health had not been so constantly concerned with the 
operation of the largest plant for the care of sickness in the city, a negative 
function so far as modern public health work is concerned. 

The fact that the Health Officer holds his position under Civil Service 
rules, makes for permanency of tenure and a most desirable continuity of 
policy. 

The annual budget for the Department of Health is presented to the 
Board by the Health Officer and when approved by them, is submitted to 
the Mayor and Board of Supervisors. Of the total appropriation of about 
$2.75 per capita for the Board of Health, only S7y 2 cents per capita was 
devoted to health services proper, a sum which in 1923 was less than that 



Services for Health and Its Protection 7 

appropriated for similar functions in any of the cities of the country of 
over 500,000 population, except St. Louis and Chicago. 

Aside from the Division of Hospitals and Charities which deals with 
the care of the sick and the poor of the city, the functions of the Board 
of Health, as carried out by their executive, the Health Officer, are the 
following : 

Sanitary supervision of public property and institutions, together with 
the abatement of nuisances. 

Enforcement of pure food laws, including control of eating places, 
food handlers, meat, milk and dairy products, etc. 

The control of communicable diseases, with particular attention to 
tuberculosis and venereal diseases, in special clinics. 

Protection of maternity, infancy and childhood through prenatal and 
baby stations, and school medical inspection, supervision of foster homes, 
midwives, etc., under the Division of Child Hygiene. 

Epidemiology and vital statistics. 

Diagnostic laboratory service. 

The services provided out of the appropriations are probably as well 
balanced and effective as the funds permit, but it is suggested that less 
emphasis upon environment and the details of sanitary supervision with a 
corresponding increase in the detection and isolation of the common com- 
municable diseases of childhood would show more direct results in reducing 
preventable sickness and death. 

It is obvious that with so very limited an appropriation for public 
health services, about one-half the per capita amount made available in 
Detroit and Toronto, the Health Officer cannot carry on many of the 
profitable activities recognized as fundamental. An excellent picture of 
a well-balanced and adequately supported municipal health department for 
a city of 100,000 is to be found in the Report of the Committee on 
Municipal Health Department Practice of the American Public Health 
Association, U. S. Public Health Service Bulletin 136, July 1923, pages 
247 to 274. 

If the Board of Health should adopt as its program the development 
of health services suggested in this report, it is probable that the force 
of public opinion and the powerful influences of the private health agencies 
of the city would soon be so strong in support that adequate appropriation 
would be obtained. 

Where the two functions, care of the sick and protection of health, are 
carried out by the same executive or under the same department of govern- 
ment, it is almost inevitable that the more pressing demands of immediate 
suffering will be generously met while the less obvious work of prevention 
lags for lack of public understanding of its significance. 

The work of the Department of Health has been observed and instead 
of including here a record of volume or quality, only such functions as are 
seriously handicapped or wholly unprovided for will be discussed, to 
point out some of the major problems which might well engage the 



8 Hospital and Health Survey 



attention of a Health Council if such a study and program group is 
created under the auspices of the Community Chest. 

Protection against diphtheria by the widespread demonstration of 
toxin-antitoxin immunization of young children (at 2 years of age) requires 
additional medical and nursing personnel and an expansion of educational 

efforts. 

The problems of tuberculosis and venereal disease control are treated 
of later in this section, but it is obvious that satisfactory efforts at control 
of these diseases will depend largely upon the more complete reporting of 
patients by physicians, and better facilities for treatment of groups of cases. 

Protection of maternity and childhood is seriously hampered by lack 
of personnel to supervise midwives, to offer prenatal instruction, to examine 
children of the pre-school age and to provide a thorough medical inspec- 
tion of children in school and in industry. 

Public health nursing under the Department of Public Health is 
carried out by 28 school nurses, 5 infant welfare nurses and 9 tuberculosis 
nurses. Six of the cities of 500,000 or over spend more than San Francisco 
per capita for their public health nursing under a health department. (San 
Francisco $0.07, Pittsburg $0.09, Los Angeles $0.09, Buffalo $0,093, New 
York $0.10, Baltimore $0.14, Detroit $0.22.) 

Laboratory service and food, milk and dairy inspection are suitably 
provided for. 

Plumbing and housing inspection are properly functions of a building 
department and as carr ied out co rjtrihivt^ little to the health of the 
community. 

The final step in protection of the water supply by chlorination having 
been made, this is no longer a sanitary problem. 

The gradual elimination of privies is quickly bringing this potential 
nuisance and sanitary risk to an end. 

Health education is wholly unprovided for and in this appears the 
most striking inadequacy of public service by the Board of Health. 

Reports of births, deaths and sickness, the analysis of their distribu- 
tion by race or nativity, by age, sex and city district, by week or month 
of the year in comparison with the experience in previous years and in 
other cities, constitute the elements of health bookkeeping and epidemiol- 
ogy. Provision is not made for suitable tabulation of these facts and no 
annual report is published, thus depriving the citizens, as well as the public 
and private agencies dealing with health and disease, of a means of 
education and valuation of work done or uncompleted, which is of the 
utmost importance. 

In summing up the situation so far as the Health Board and its 
Divisions of Hospitals, Charities and Health are concerned, it appears that 
San Francisco, with a high per capita wealth, provides with much gener- 
osity for the sick but is rather parsimonious in its appropriations for pre- 
vention of disease. This is probably due to the lack of public information 
upon the subject of health, the possibility of attaining it, and the necessity 
of paying for it. 



Services for Health and Its Protection 



Chapter 2 

PROBLEMS IN HEALTH SERVICE 

As each of the major issues of preventive medicine has received special 
attention, it has become increasingly apparent that no preventable disease 
which is widely prevalent can be handled as a problem apart from other 
disease or from the social and economic problems of the entire community. 
Few health problems are limited to the poor or rich alone, to the factory 
hand or the mother in the home. As a result of a broader recognition of 
the interrelationship of causes and effects of diseases, we have seen first 
one and then another of the special campaigns and private organizations for 
health protection gradually enlarge the scope of their respective programs 
to include all groups in a community. 

It is not an exaggeration to say that at present the tuberculosis, child 
hygiene and venereal disease programs cover an almost equally wide field 
and that the logical completion of any one would constitute a suitable com- 
munity health service. 

Similarly, mental hygiene touches very closely child hygiene work at 
almost every point, and heart diseases cannot be checked without further 
progress in control of syphilis and the communicable diseases of childhood. 

Even though cancer is so nearly the burden of one age group, the 
relation of maternity, personal hygiene, occupation, syphilis, neglected 
teeth, etc., to certain types and locations of malignant growths brings the 
cancer campaign into necessary relationship with other fields of preventive 
effort. 

From these brief suggestions it can be inferred that no precise separa- 
tion of functions, no isolation of agencies, can be allowed in public health 
work, and furthermore, that in no other phase of community relationships 
is there a greater need of central direction, of accepted leadership and of 
close association among the workers to prevent confusion of opinion, 
duplication of effort, and waste of public and private funds. 

HEALTH EDUCATION 

There is at least one element in every phase of public health work 
upon which efforts and resources can be combined, namely, that of educa- 
tion in health. 

San Francisco has made no provision for educational service under its 
Board of Health, although it is now almost ten years since the Bureau of 
Public Health Education was established in the Department of Health of 
New York City, and fifty-two of the eighty-three cities of the country of 
over 75,000 population carry on enough educational work to demand a 
head for this activity under the health officer. Thirty-nine of the eighty- 
three cities publish regular bulletins. Occasional lectures by the Health 
Officer of San Francisco, and by the doctors and nurses of the staff, 



10 Hospital and Health Survey 



and a portable exhibit, constitute the only health educational work of the 
Health Department. There is no bulletin or annual report, no press service, 
no systematic stressing- of seasonal dangers, or successes in diminishing 

sickness. 

There is a similar lack of policy and provision for health teaching 
among all the private agencies, except the Tuberculosis Association, in 
spite of the fact that instruction to the individual is the basis of preventive 
work for the expectant mother, the school child, the families of the tuber- 
culous, as carried out at the clinic and at the bedside. 

The exceptions are the newspaper publicity and instructional service 
carried out by an organization of physicians, developed primarily to pro- 
tect the medical profession and the public against the mischievous propa- 
ganda and attack of cults and quacks, and the weekly bulletin of the Cali- 
fornia State Department of Health, which has but a limited circulation in 
San Francisco, chiefly among the doctors, nurses, teachers and ministers. 

Of course, there are lectures given on the prevention of cancer, on 
child hygiene, on tuberculosis, etc., to occasional audiences, but there is 
nothing in San Francisco that can be called an educational policy for any 
age group or class of the community, planned and carried out year after 
year with the definite object in view of giving the reading and understand- 
ing public all they can use of the abundant knowledge of the causes and 
means of preventing disease. 

Xor is there in the schools of the city such a system of progressive 
teaching of health habits, of the simple facts of biology, and of their 
application to the common situations of personal, family and community 
life as will arm the child against preventable disease, against superstition, 
fear and ignorance in health matters. 

Until the police power of the State, as expressed in the authority of 
the Board of Health, and the services for the sick are supplemented by 
an aggressive continuous education of the community, and particularly of 
the school children in the meaning of health, the way it may be attained 
and the causes of its destruction, no permanent impression will be made 
upon the most important causes of human disability. 

The methods, the subject matter, and the costs of public health educa- 
tion are well known. 

To accomplish results there are needed : 

(a) Inclusion of teaching of health habits, of personal hygiene, of 
health protection in the schools. 

(b) The establishment of a division of health education, with an 
appropriation of approximately $20,520 4 in the Department of Health. 

(c) A conference group or committee of the proposed Health Coun- 
cil devoted to the study and promotion of health education by public and 



4 Report of Committee on Municipal Health Department Practice, U. S. P. H. S. Bul- 
letin No. 136, July, 1923, page 273. 



Services for Health and Its Protection 11 

private agencies. Membership might properly include representatives of 
the Board of Health, the Board of Education and of the private health 
agencies. 

TUBERCULOSIS 

San Francisco has been so favored by the initiative of its professional 
medical and social teachers and students of tuberculosis, that organization 
and services have followed closely upon plan and program, until at present 
most of the facilities required are provided. 

Excellent analyses of the tuberculosis situation have been made within 
the past two years, and reports based upon these, already in the hands of 
the Council of Social and Health Agencies, were studied. It is not neces- 
sary to do more than refer to these careful studies and emphasize their 
conclusions. 5 

The following brief headings give an excellent picture of the re- 
sources, the results and the present needs as understood by the San 
Francisco Tuberculosis Association : 

Defining the Tuberculosis Problem in San Francisco 

I. MACHINERY FOR THE CONTROL OF TUBERCULOSIS 

1. Bureau of Tuberculosis, Department of Public Health, with a chief in 
charge of six Chest Clinics throughout the city, eight visiting nurses, who follow- 
up patients in the homes, educate families, and bring contacts to clinic. One 
supervising nurse at hospital in charge of clinics and follow-up. 

2. Tuberculosis Hospital, Department Public Health. Two hundred and 
forty beds for all types of tuberculosis in adults. Highest type of plant and 
medical care. 

3. San Francisco Tuberculosis Association, an organization dedicated by pri- 
vate endeavor as a laboratory where methods for fighting tuberculosis may be 
initiated and demonstrated and their administration ultimately turned over to the 
proper public authority. 

4. Semi-philanthropic institutions out of town: Arequipa Sanatorium (46 
beds) for early tuberculosis in wage-earning women, for educational work and 
research; San Mateo Preventorium for Boys (15 beds); Stanford Convalescent 
Home (16 beds) for children; Hill Farm (40 beds) convalescent home for children. 

5. Child Welfare Program of the Department of Public Health with eight 
health centers, including prenatal instruction, well-baby clinics, supervision of 
boarding homes for children, examination of children of pre-school drive. Also 
children's clinics in eight hospitals and one private health center. 

5 (a) Communication (January 16, 1922) from, Dr. William C. Hassler, as Chairman 
of the Health Agencies Section, to H. J. Maginnity, secretary Council of Social and 
Health Agencies, pages 5-9. 

(b) Community Resources for the Control of Tuberculosis According to Age Periods; 
Prevention and Treatment for the Child of Preschool Age; The School Child; The 
Youth (16-25), by Miss Elsie Krafft of the San Francisco Tuberculosis Association. 

(c) Follow-up Study of San Francisco Tuberculosis Hospital. Presented at the 
California State Tuberculosis Association, February 3, 1922. Miss Elsie Krafft. 

(d) Annual Report of San Francisco Tuberculosis Association, 1922. William Ford 
Higby, general secretary. Mortality Tables; Community Resources; Health Training; 
Nutrition Work. 

(e) Excerpt from Report of Survey of Tuberculosis Clinics of California. National 
Tuberculosis Association. 



1- Hospital and Health Survey 



6. School Health Program through co-operation of Department of Public 
Health, Board of Education and San Francisco Tuberculosis Association. Child 
Health Education in twelve schools, Nutrition Classes in twenty schools, Bread 
and Milk Lunches in all schools, Intensive Health Work in one school, two out- 
door schools with clinic service and follow-up Board of Health nurses. Five 
>chool doctors, 23 school nurses, 7 dentists, 1 dental hygienist, 1 optometrist. ' 

7. Health Education: Health service in dailies, Radio Health Talks, Uni- 
\ ersity Extension Courses, Public Health Committees, San Francisco Center. 

S. Outdoor Life Program of Boy Scouts, Camp Fire Girls, Y. M. C. A., 
Y. W. C. A., Playground System throughout city. Many vacation camps in 
summer and two vacation homes for children, five for girls and young women. 

9. State aid to children of tuberculous parents, free milk and eggs from five 
relief agencies and supplemental aid to families. Children committed to Chil- 
dren's Agency through Juvenile Court and given special care and supervision. 

10. Legislative basis for work in regulations for pure milk and inspection, 
pure water and food supply, reporting of contagious diseases, interstate carriers 
of contagion. 

II. IS THE MACHINERY EFFECTIVE?— ACCOMPLISHMENT 

1. Reduction of death rate from 330 per 100,000 of population in 1900 to 
109 per 100,000 in 1922. 

2. Development of clinic system from one central clinic in 1909 to six clinics 
throughout the city in 1922. Growth of clinic attendance from 1599 in 1909 to 
5981 in 1922. Three hundred and forty-six new cases in 1909 compared with 
1804 new cases in 1922. 

3. Development of visiting nurse system from 2 in 1908 to 8 in 1922 and 
1 supervising nurse from the association, resulting in increase of home visits from 
16 in 1908 to 9898 in 1922. 

4. Reduction of undernourishment in children from 11 per cent in 1921 to 
2.5 per cent in 1922. 

5. Finest municipal tuberculosis hospital in the United States, with high 
type of medical care. 

6. Passage of amendment authorizing country sanatorium. 

III. GENERAL COMMENT 

1. Xot enough hospital beds. Total annual deaths, 637. Allowing one bed 
for each annual death, reveals the inadequacy of the present 240 beds. 

2. Total annual deaths include forty-eight children under 10 years. But 
there is no children's ward in the Tuberculosis Hospital, and no other facilities 
for their care in active cases 

3. Inadequate registration. Registration for 1922, 1533 active cases, or 2.4 
cases to a death. Average registration in most cities, 3 or 4 cases to a death. 

4. Failure to reach cases in early stages. Majority of cases admitted to 
Tuberculosis Hospital are moderately or far advanced. Fifty per cent die in 
the hospital. No sanatorium for early cases in men such as Arequipa is for 
women. 

5. Difficulty of the migratory tuberculous. Fifty per cent of the patients 
in the hospital are floaters. 

6. Need of better housing facilities for single homeless men. 

7. Food-handling jobs, a favorite with ex-patients and no law to prevent. 
(Ordinance now being framed.) 

8. No facilities for the industrial rehabilitation of discharged patients. (Plan 
now pending.) 



Services for Health and Its Protection 



13 



9. Inadequate industrial health service. Only fifty welfare departments and 
only twelve with medical examinations. Survey being made, shows failure to 
recognize tuberculosis. 

The thorough study of the subsequent history of tuberculous patients 

discharged from the San Francisco Hospital is a model worthy of imitation 

by other cities. The situation is briefly expressed in the following 

quotations : 

The immense waste evidenced in all these figures reveals the inadequacy of 
one hospital unit to cope with the problem, even when that unit is supplemented 
with a follow-up system. The hospital renders invaluable service in the commu- 
nity program for control of tuberculosis by segregating and caring for far- 
advanced and dying cases which would otherwise be a menace to public health. 
But this solves only part of the problem. Three links are needed: (1) The hos- 
pital itself; (2) The country sanatorium; (3) A half-way house between the wards 
and the working world. Our country sanatorium is about to be realized. What 
is now wanted is a workshop where, under medical supervision, discharged 
patients could be trained in new occupations within their strength, Combined 
with it, but preferably under separate management and separately housed, should 
be a boarding-house where they could be properly fed and lodged and supervised 
until they reach normal health and working capacity. 

It is significant that the patients reported well and working are those who 
had some education and training that made possible a less strenuous type of 
work than the average. Among them are engineers, carpenters, painters, motor^ 
men-, tailors, garment-cutters, salesmen, clerks, a radio-operator, a photographer, 
and a mechanical dentist. 

Seeking an expression of opinion on the workshop idea, a letter was sent 
out, and all those possible to reach personally were interviewed. Hearty endorse- 
ment came from various parts of the country, from those who were struggling 
on part-time work, as well as from those who had experimented successfully for 
themselves and wanted to see others try. While a pathetic few, concluding that 
the workshop was already in operation, called at the hospital to begin work! 

With a country sanatorium and a workshop to make more effective the 
function of the hospital, undoubtedly we could change the vicious circle here 
represented, into a back-to-health-and-economic-efficiency cycle for a large num- 
ber, with a great saving of money and medical skill: 

San Francisco 
Tuberculosis Hospital 



Unsanitary 
Lodging House 



Following the Fruit 



Walking the Ties 




Back to 
Hospital 



Working in Kitchens 
and Restaurants 



Back to City 
and Unsanitary 
Lodging House 



Working in 
Camps 



1"* Hospital, and Health Survey 



Among the significant findings presented in the foregoing report are 
those dealing with the readmission of tuberculous patients to hospital care, 
and the subsequent history of patients discharged from the San Francisco 
Tuberculosis Hospital : 

"Readmissions to the San Francisco Tuberculosis Hospital in a three-year 

period — 195 patients. 

Second admission 179 

Third " '. ..V '.['.'.'. 19 

Fourth " ' 5 

Fifth " ;.;;;; i 

Two of the cases total ten years in the hospital on readmissions and one 
five years. 

Of the 914 cases investigated we have these figures: 

Found living 255 Left the city 175 

Dead 218 Left the State 56 

Still missing 441 Went to the country 61 



Went south . . 50 



914 

Of the 255 found living: 

Well and working 88 or 34% 

Symptoms 47 

Again in S. F. Hospital 46 

In other hospitals 46 

In Relief Home 30 

Reporting to our clinics 58" 

The Annual Report of the San Francisco Tuberculosis Association for 
1922 in the following important statements puts the matter tersely: 

"A decline of 48 per cent in the death rate from tuberculosis is noted 
since 1910. The greatest decline is noticed in 1906, during the period of 
the earthquake and fire. The death rate in 1905 was 322.2 and in 1906, 
209.8." 

In the tuberculosis field alone has there been any thoroughgoing plan 
formulated and carried out, as far as resources permitted, for widespread 
instruction in the preventable causes of disease and the personal and com- 
munity resources for its control. The demonstration and research work in 
the Daniel Webster School, in the study of the incidence and reduction of 
nutrition, and elsewhere in various phases of medical, social and administra- 
tive work for the tuberculous, reflects great credit upon the character of 
direction, initiative, and public service of the San Francisco Tuberculosis 
Association. 

The study of the National Tuberculosis Association brings out the 
fact that a more nearly complete reporting of tuberculosis should and can 
be accomplished, and emphasizes the extent and result of shortage of beds 
for active cases of the disease: 

There were in San Francisco County but 1205 cases reported in 1921, most 
of these being in the city. The number of reported cases is very low, indicating 
a lack of co-operation of the medical profession with the Board of Health. The 
Commissioner of Health has carried on a follow-up campaign to gain better 
co-operation, but thus far has been only partially successful. That physicians can 
and will co-operate, when sufficient pressure is brought to bear, is shown by the 
number of reported cases in New York City and Chicago. 



Services for Health and Its Protection 



15 



The shortage of beds means that hundreds of far-advanced cases are living 
and dying in their homes, many of them among children. Eight active cases for 
every annual death is a conservative ratio. There are, therefore, at least 4350 
active cases in San Francisco. 

Attention is called also in this study to the shortage of public health 
nurses, to the lack of training of the nurses now engaged in this work, 
the special problems of tuberculosis visiting and home supervision, the 
need of expert supervision to raise the standard of field work, the in- 
completeness of clinic records and the inadequacy of home follow-up of 
discharged patients. 

The study suggests the considerable advantages to be obtained . in 
planning local work, by analyzing the distribution of deaths from tuber- 
culosis by race and age groups, as expressed in the following tables : 

Tuberculosis Deaths by Race and Age 



Race 



Deaths 



White 564 

Chinese 53 

Japanese 21 

Negro 14 



Rate per 


• 


No. of 


100,000 


Age 


Deaths 




Under 1 year. . . 


• • • ■ • « 




1 to 4 yrs.. . . 


.... 10 


111.9 


5 to 14 " 


.... 38 


725.5 


15 to 24 " ... 


.... 25 


382.7 


25 to 34 " 


.... 108 


552.7 


35 to 44 " 


. ... 143 




45 to 54 " 


....110 




55 to 64 " 


.. . 60 




65 and over .... 


.... 26 



CHILD HYGIENE 

It has been remarked above that certain phases of public health work 
are so all embracing that a complete program for either one of them would 
constitute a satisfactory community service. Certainly if San Francisco 
could put into effect the entire plan for the protection of maternity and 
childhood which the leaders in this city in these specialties of preventive 
medicine have though out, the accomplishment would be notable. 

The Health Officer, the teachers of pediatrics, obstetricians, women's 
organizations and various social agencies appear to be in entire agreement 
as to the desirable elements which should be included in a child health 
program. 

Upon the structure of the health centers established primarily to reduce 
infant mortality, and with the well-established medical and nursing service 
in the public and parochial schools, both under the Department of Health, 
there has been built a constantly broadening service often depending upon 
private resources to initiate, demonstrate and popularize new phases of the 
work, but in the long run all functions appropriate for public operation 
gradually being assumed by the Board of Health as the proper burden of 
the taxpayer. 

Recent studies have been made by the Public Health Committee of 
the San Francisco Center of the California Civic League upon the extent 



16 Hospital and Health Survey 

and character of care given to the expectant mother and to the mother 
and child during* the post-partum or neo-natal period. 

That this was needed is apparent from the still high mortality rate of 

infants under one month of age and of mothers from puerperal causes, as 

can be seen from the following table: 

1918 1919 1920 1921 1922 

Total Births 8466 8386 9044 9167 8656 

Deaths Under One Month 115 304 325 212 289 

Deaths of Mothers from Puerperal Causes.. 42 71 83 56 60 

Prenatal supervision is recognized now as an obligation of the Health 
Department and of the maternity services of hospitals, but the standards of 
much of this work are low, the mothers are not commonly reached until 
they are well along in pregnancy, often in the seventh and eighth month ; 
Wassermann reactions are not taken as a routine, education of the mothers 
is undertaken without a preliminary medical examination, urine tests and 
blood pressure observations are. not made uniformly and there is rarely 
any follow-up of the patient in the home to secure good personal hygiene. 

The standard of prenatal work at Mount Zion and at University of 
California and Lane and Stanford University Hospitals, is excellent. 

Post-partum follow-up in the homes is not carried out adequately as 
a rule, though here, as in the prenatal work, both quantity and quality of 
service are improving. 

The lack of complete prenatal and of any post partum care, at the 
San Francisco Hospital causes much difficulty for women who must, for 
these periods, look to this hospital's clinics for attention. 

While the effort at the Haight Street Clinic or Children's Health 
Center is entirely laudable as a private undertaking, it is obvious that 
education alone will fall short of the service needed if it is not supple- 
mented by medical examination and supervision of the expectant mother by 
nurse visits in the homes and such exact methods of diagnosis as the use 
of the Wassermann test and tests of urine and blood pressure. 

The standards adopted several years ago and steadily maintained and 
increased in the work of the Maternity Center Association in New York, 
are nowhere observed in all their completeness in San Francisco. 

The time of one nurse is not suffitient to carry out adequate super- 
vision of the 105 licensed midwives, the problems of whose nationality, 
education and racial customs are of themselves no small matter for ad- 
justment to the standards of the Board of Health. 

Nationalities of 105 Midwives 

Italian 37 English . 2 

Japanese 24 Spanish 2 



Russian 8 Belgian 

United States 8 Chinese 

German 7 Danish 

Swiss 5 Hungarian 

Unknown 4 Serbian . . 

Austrian 2 Swedish . 



Services for Health and Its Protection 17 

Supervision of well babies lacks only in volume of service to meet 
all reasonable expectations and the results to date are admirable. A report 
of five months' study of the whole range of health work for children was 
made by the Committee of the San Francisco Civic Center. The con- 
clusions submitted express in general the best opinion of the city and should 
be used as the basis of arguments before the public authorities. 

The substance of the matter is the fact that the appropriations for the 
Department of Health are too meager to provide sufficient doctors and 
nurses for health center, infant, pre-school, and school child supervision, 
and an organization which would justify and require the full time of a 
specialist in child health as the chief of a bureau. 

This will all doubtless come about when education of the public and 
the public officers is insistent and continuous. 

The detailed recommendations to complete the child health program 
prepared after individual and group conferences with those who have 
studied the children of San Francisco as no brief survey could possibly do, 
will be found in Section IV. 

Too much praise cannot be given to the departments of pediatrics 
at the two university medical schools which have made their teaching 
staffs and their clinics available in countless ways to supplement the work 
of official and private agencies devoted to child welfare. They are carry- 
ing on active research in clinical and administrative problems in schools 
and health centers. 

MENTAL HYGIENE 

In San Francisco there is just one free bed designated for the care of 
patients suffering from mental disease. There are a few beds in privately 
supported hospitals where those able to pay three dollars a day or more 
can receive attention, but it must be explained that nowhere in the city is 
there hospital or clinic service where the resources or environment and 
personnel now known to be essential or at least desirable for the diagnosis, 
observation and treatment of mental and nervous disease, have been as- 
sembled for either the rich or the poor. 

There is no greater lack in the entire scheme of hospital and health 
services in this city than in the field of mental disease, whether for treat- 
ment or prevention. 

Fortunately, however, this rather astonishing inadequacy which is 
rather typical of Pacific Coast cities, is not due to rivalry or controversy 
among those informed on the subject. 

In February of this year, the President of the Board of Health 
declared in no uncertain terms his conviction as to the importance of the 
mental problem of San Francisco, and the fact that it was a burden for the 
community to assume through public agencies primarily. We can do no 
better than to quote from his ringing appeal for a radical change in the 
attitude of the public toward mental disease, for a change in the method 



18 Hospital and Heai/th Survey 



of commitment and for immediate provision for mental disease patients 
in the temporary or curable stages of these states in the San Francisco 
Hospital (San Francisco Examiner, February 12, 1923) : 

There is a growing and imperative demand coming from all quarters, medical 
and lay, for a change in the manner of caring for and committing insane patients. 
This demand does not concern the acutely insane alone, but includes what are 
called "border-line cases" or, to use a common expression, the cases of all of 
those persons who are "acting queer." The demand is for provision of proper 
hospital conveniences for the deliberate observation of all cases of the mentally 
afflicted by trained psychiatrists. .... 

As a member of the Board of Health, the conviction has been forced upon 
me more and more strongly in the last year or two that we are not doing our 
full duty when we fail to offer a place of refuge to those needy persons who are 
verging on mental incapacity or are subject to some form of mental disturbance. 
The mandate of the charter makes no distinction between the poor who are 
physically ill and those who are suffering mentally. It demands that we care 
for the sick poor. . . . 

By pursuing the same course, two small wards, one for each sex, could be 
opened in the San Francisco Hospital, and this most important work of the care 
for and observation of mental cases be properly undertaken; then, when its 
utility had been proved beyond doubt, a separate psychopathic building could be 
provided. 

There are in many homes in San Francisco people who are mentally affected, 
whose friends and relatives prefer to bear the pain and burden of caring for them 
in secret rather than go through the repellent process of swearing out a warrant 
and having a commitment to a State asylum follow. ... 

A period of observation would enable the trained psychiatrist to decide what 
was best for the patient, and in many cases start the sufferer on the road to 
recovery rather than to the asylum. 

That this latter statement may not be deemed presumptuous, coming from 
a non-medical man, I state that an eminent psychiatrist in this city, in charge 
of the psychopathic ward of one of our best private hospitals, said as recently 
as two days ago: 

"The number of cases that are committed to our State asylums for the insane 
that Avould, under proper treatment, be restored to sanity, is colossal." 

The California Society for Mental Hygiene represents the expert pro- 
fessional, and a large sympathetic lay opinion and interest in this field, 
but without specific local program and support, a beginning can hardly 
be said to have been made in humane, just, intelligent, scientific salvaging 
or protection of the sick, and education or prevention among the well in 
the realm of mental, nervous and behavior disorders which cause so large 
a proportion of our delinquency, dependency and family distress. 

Under the circumstances, it seemed best to obtain a body of opinion 
by conference with those who had given close attention to the subject, and 
the following statement is offered with the entire endorsement of the 
Survev. 

The following organizations were represented at the conference : Cali- 
fornia Society of Mental Hygiene ; California State Medical Society, Neuro- 
psychiatric Section San Francisco County Medical Society; State Board 
of Corrections and Charities; San Francisco Board of Health; Juvenile 
Protective Association; Criminological Institute of San Francisco; San 



Services for Health and Its Protection 19 



Francisco Neurological Society ; University of California ; Stanford Uni- 
versity; San Francisco Hospital; St. Francis Hospital. 

Their report follows : 

HOSPITAL BElD SERVICES 

We find that there are three main general hospitals in San Francisco in 
which the need of beds for mental cases is especially acute, viz., the University 
of California, Stanford University, and San Francisco Hospital.. 

It is estimated that the minimum need of beds in these hospitals at the 
present time is as follows: 

University of California — Fifteen for diagnostic purposes and 25 for treat- 
ment, or a total of 40 beds. 

Stanford University — Ten for diagnostic purposes and 25 for treatment, or 
a total of 35 beds. 

San Francisco Hospital — A total of 50 beds, the capacity of the two wards 
now available and equipped, but without personnel, and meeting the very urgent 
recognized need of care for acute committable mental cases in this municipality. 

We find that Mount Zion Hospital, St. Luke's Hospital, and Franklin Hos- 
pital are caring for a certain number of mental cases on a pay basis, but do not 
feel that they could widen the range of their services in this respect. 

OUT-PATIENT CLINICS 

With reference to out-patient clinics, we find that there are only two clinics 
daily available, viz., University of California and Stanford, and that there are 
four at fairly frequent intervals, viz., at Mount Zion, St. Luke's, Polyclinic, and 
Mary's Help Hospitals. 

We feel that these should be developed further, rather than add new clinics 
at the present time. In each case we find that the out-patient services are woe- 
fully inadequate; patients wander from one clinic to another; there is very little 
contact with the home conditions or attempts to modify the same, and in each 
case this seems to be due to a lack of personnel, and not to the lack of vision 
or reasonable desires of the respective clinics. 

We feel very strongly that in the two main clinics, viz., University of Cali- 
fornia and Stanford, there should be in each one specially trained neuro-psychia- 
tric social service worker, one of the usual social service workers, one recording 
stenographer-clerk, and one psychologist of the standard of the American Medi- 
cal Psychological Association. The relationship of psychiatric cases with courts, 
social service organizations and families is much wider than in any other type 
of medical case, and in each instance, we find that psychiatric service is inade- 
quately equipped and suffers partly because it is a subdivision of another service. 

REQUIREMENTS OF SCHOOL CHILDREN 

We find, according to the last census, that there are 85,000 school children 
in San Francisco. 

That there has never been a systematic examination of these children from 
a neuro-psychiatric point of view. 

That there are at present one ungraded school and 18 classes for ungraded 
children in other schools, but that the waiting list of this sort is probably twice 
the number of those at present cared for. 



20 Hospitai, and Health Survey 



We believe that the beginnings of juvenile delinquency are found among 
these children, and that the most successful preventive measures can be taken 
at this point. Some desultory work is being done as becomes possible at the 
University of California to meet conditions in certain specified schools, but 
this inspection is not yet completed, and in no sense gives an adequate idea of 
the situation in all of the schools. 

We are, therefore, very strongly of the opinion that an adequate psycho- 
logical and psychiatric medical inspection of these schools is very much needed, 
and that in San Francisco this would necessarily involve the use of full time 
paid psychiatric and psychological personnel and such social sendee workers 
and clerks as are requisite. 

EMERGENCY COMMITMENT LAW NEEDED 

There is in California at present a voluntary commitment law, which is 
entirely satisfactory. There is, however, no emergency commitment law, and 
we regret very much that it is impossible to make use of the State Hospital 
service unless the patient is willing to go there voluntarily. In this connection, 
however, we are strongly of the opinion that the mental hygiene efforts referred 
to above would make possible the parole of a great many cases from, the State 
hospitals who are now retained there because of the impossibility of finding any 
agency to supervise them outside of the State hospitals. 

Judging from the experience in other states, we are of the opinion that 
the saving to the taxpayer in removing these patients from State hospitals 
would compensate for a large part of the increased expense in developing a 
mental hygiene service for San Francisco. 

In the various northern State hospitals, there are at present patients from 
San Francisco to the extent of from one-third to two-thirds of the admissions 
to the State hospitals, that is, some hospitals receiving one-third and some 
two-thirds of all their patients from the population of San Francisco. 

DEMONSTRATION CLINIC FOR DELINQUENT CHILDREN 

While we find a great deal of interest in San Francisco in the abstract 
questions of mental hygiene, we feel that it is very essential that there should be 
a demonstration clinic for a period of at least six months, which would show the 
actual conditions in San Francisco. 

We believe that the question of juvenile delinquency is very closely as- 
sociated with the question of the survey of school children in San Francisco, 
and we see no reason why the conditions should be any better in San Francisco 
than in Cincinnati, St. Louis, Cleveland and elsewhere. 

According to the reports from these places, we may expect that San 
Francisco will find that two-thirds of her problems of delinquency and dependency 
have to do with mental hygiene. It is evident, therefore, that a demonstration of 
San Francisco's needs would lead to more effective effort than we have witnessed 
in the past. 

We beg to submit that San Francisco's needs are urgent and greater than 
those of many cities of which we have knowledge. 

This restrained, moderate and well-considered statement of fact and 
recommendation suggests rather than discloses the truly astonishing neglect 
of the most pitiful, as well as the most hopeful, of those who need medical 
and social care. 

The Survey is deeply indebted to the authors of the foregoing state- 
ment of the situation. 



Services for Heai/th and Its Protection 21 



VENEREAL DISEASES 

(Social Hygiene) 

There were reported to the Department of Health in 1922, cases, 

deaths and isolation in hospitals of syphilis and gonorrhea as follows : 

Cases Hospital 

Reported Deaths Admissions 

Syphilis 1011 82 42 

Gonorrhea 935 13 



1946 82 55 

Of course, no such statement is to be accepted for a moment as repre- 
senting even an approximation of the true situation. 

The cases reported are with rare exceptions those applying for 
treatment at public dispensaries and hospitals. There are probably at 
least fifty times as many cases, not all in the communicable stages of the 
diseases, of syphilis and gonorrhea at any one time in the city of San 
Francisco. A good reporting of these diseases would be inferred if noti- 
fication of 5400 cases, or 1000 for each 100,000 of the population, was 
made to the Health Department. 

It is estimated that at least 500 cases for each 100,000 of the popula- 
tion (2700) will require treatment through public agencies in a year. 

The report of deaths deals only with those directly and obviously due 
to the effects of syphilis and does not include deaths from paresis, locomotor 
ataxia, luetic disease of heart, arteries, or other systems and organs. 

The report of hospitalization represents only those patients admitted 
to the San Francisco Hospital for detention purposes, as venereal diseases 
are not admitted under these diagnoses to any other hospitals in the city. 

Since 1906 there have been various groups, medical, social, official and 
lay, which have for one phase or another of the problems of venereal 
disease, organized, started reforms and then ceased to function, until at 
present there is no body of informed opinion prepared to influence public 
or private agencies in the prevention and control of syphilis and gonorrhea. 

Studies were made of hospital expenditures and days of care for 
venereal diseases as long ago as 1910. For a while a municipal clinic cared 
for the suspected common prostitutes from the "cribs" of the old "Barbary 
Coast/' Then there was a period when attempts at sex education held the 
public interest. The elaborate and largely effective . federal effort during 
the war was followed by a period of laxity in public interest and official 
action for protection or treatment. 

Outside of the activities of the venereal disease divisions of the 
State and City Health Departments and the usual diagnostic and treatment 
services of several dispensaries, it is fair to say that nothing of a con- 
structive, educational, recreational, social or legal character is being done 
in San Francisco. In spite of the efforts of several groups in the past, 



22 Hospital and Heai/th Survey 



many of which were productive of valuable but temporary results, nothing 
is now under way or apparently contemplated in the shape of professional 
leadership which can be relied upon to make headway against public in- 
ertia, indifference, and ignorance of this group of prevalent insidious and 
highly communicable and preventable diseases. 

IVrhaps first in importance is the incompleteness of reporting by the 
physicians of the city as required by law. A judicious mixture of educa- 
tion, of public spirit, of official pressure through the San Francisco Medical 
Society, the hospitals, the Health Officer and the State Department of 
Health might be expected to correct this. With the medical profession 
indifferent and resistant to reasonable requirements of the health depart- 
ment, education of the public will certainly lag. 

There are provided for the indigent sick only two clinics for venereal 
diseases, in the morning and evening at the University of California 
Hospital and in the evening at the Lane and Stanford University Hospital. 
These services are of a high grade, but represent only twenty-three dis- 
pensary hours a week and do not include social or follow-up supervision 
of active cases sufficient to keep track of patients until they are cured. 
At the city prison and at the central office of the Department of Health 
examining and treatment stations are maintained. Co-operation among 
the departments of the city administration for the discovery and isolation 
of sex offenders who are infected is reasonably effective. 

In San Francisco as in most other cities the ancient prejudice, really 
an expression of so-called "moral" rather than sanitary or medical opinion, 
against men, women or children suffering from venereal disease whether 
acquired "innocently" or through some a-social practices, results in the ex- 
clusion from the benefit of hospital care of these sick and suffering patients. 

This self-righteousness of hospital administrations bears heavily upon 
patients needing bed care during some period of the course of their disease 
and contributes to the neglect of intensive and adequate treatment which 
permits a prolonged period of communicability of many patients. 

Beds in every general hospital, and in certain types of cases beds in 
general medical or surgical wards for men and women should be made 
available for cases of syphilis and gonorrhea in the communicable stages. 
Hospital technique under all but the crudest of conditions is quite adequate 
to prevent the transmission of infection to other patients. 

If there should be established a Health Council, representative of all 
the interests of public bodies in health, it w r ould seem essential that a sub- 
committee or functional group be organized within its members to assume 
responsibility for studying the venereal disease situation in San Francisco, 
to reassemble the many scattered elements of interest of the groups 
formerly active in this field, to prepare a program of practical nature 
embracing the preventive resources of social, educational, recreational and 
sanitary character as well as the facilities required for treatment and re- 
habilitation of the sick, and then to develop public opinion and resources 
to put plans into effect. 



Services for Health and Its Protection 23 



HEART DISEASES 

With the great reduction in the death rate from tuberculosis to 100 
per 100,000 of the population, attention has been drawn more than ever to 
the heavy loss of life from what is now the leading cause of death — organic 
diseases of the heart. For every 100,000 of the people of San Francisco, 
258 died in 1922 from heart diseases, while 151 died of cancer, 112 of 
violence and 100 of tuberculosis. As has been suggested in Section I, the 
relatively high proportion of persons of the later decades of life is in part 
responsible for San Francisco's particularly high death rate from heart 
diseases and cancer. 

It is but natural that the leading cause of human deaths should develop 
a demand for prevention or an explanation of our limitation or helplessness 
in the matter. It is well known that cardiac disease of children may be 
due to neglect of infections of tonsils and teeth, of convalescence after 
rheumatic, choreic, and other infectious fevers, and that syphilis is the 
original infection which leads to many an adult death from aneurysm and 
other diseases of the heart and arteries. 

San Francisco has shared, like many of the larger cities of the country, 
in providing special clinics for the diagnosis and supervision of heart 
patients, particularly children who can be spared much subsequent dis- 
ability by medical guidance, home instruction, vocational training and suit- 
able placement in work. Cardiac clinics are in operation at the University 
of California, Lane and Stanford University, Mount Zion and Children's 
Hospitals. No educational effort is under way to teach the special need 
of avoiding exposure to infection where infection of the heart has been 
once established. 

Heart patients, more than any other group, except perhaps the tuber- 
culous and mental patients, need periods of convalescent care under favor- 
able country conditions. There are in the immediate vicinity of New York, 
more than 300 beds for such patients (not chronic invalids). San Fran- 
cisco is about to have its first facility of this character, made available for 
children at the Stanford Convalescent Home at Palo Alto. 

In New York City, as many cases of heart disease are in attendance 
at the forty cardiac clinics as attend the thirty-one tuberculosis clinics and 
still the need of service and possibilities of protection and prevention 
continue to expand. 

Those who already see the importance of this problem from the social 
as well as the medical point of view might well associate themselves under 
the auspices of a Health Council to permit a crystallization of opinion in 
support of some such program as is now being developed in Boston, Phila- 
delphia, St. Louis, Chicago and New York. 

CANCER 

We are only in the infancy of our efforts to make progress against the 
high "mortality from cancer. The more careful studies of recent years 
make it appear probable that cancer is not increasing as a cause of death, 
except to the extent that the average duration of life has been extended 



24 Hospital and Heai/th Survey 



so that many more people reach the decades of life in which cancer com- 
monly occurs, or because in one or other community, owing to climatic 
or economic reasons, there is an unusual preponderance of persons of 
forty years of age and over, among whom deaths from cancer are sure 
to occur in larger numbers than in populations of lower average ages. 

Furthermore, there is accumulating definite evidence to the effect that in 
respect to certain cancers of the surface or orifices of the body, reduction 
of death rates has been accomplished by the application of the same type of 
resources which have been effective in other diseases such as tuberculosis, 
namely, early accurate diagnosis and appropriate treatment by removal or 
destruction of the localized disease process. Cancer is properly considered 
a preventable cause of death not only on account of the successes of sur- 
gery, but from the fact that we now know a great many of the causes of 
origin of cancer due to repeated local injury, irritation, and damage to tis- 
sues of the body by occupation, habits and infectious processes. 

San Francisco has shared with the rest of the country in the educa- 
tional efforts of the surgeons of the city who have given liberally of 
time to teach the public all that is proved of the causes and means of con- 
trol or cure of cancer. These educational services have been periodic and 
have usually been a part of national efforts initiated by the parent society 
of which leading surgeons of San Francisco are the regional representatives. 

San Francisco, Sacramento and Los Angeles lead the cities of the 
United States in the rate of cancer mortality. It is becoming of increasing 
importance to all parts of the country that each community should 
study its own situation and thereby contribute specific facts not only as a 
guide for its local educational and preventive efforts, but for the benefit 
of the whole nation. While in the past, most of the analysis of the cancer 
situation, as was the case twenty-five years ago in the tuberculosis field, 
was through study of deaths and death rates, it is obvious that progress 
can hardly be made further without records of the incidence of the condi- 
tion, the immediate causes and the conduct of those afflicted, with special 
reference to the promptness of diagnosis and the adequacy of the treatment 
obtained. 

Reporting of the diagnosis of cancer to the Department of Health, 
without implying* that the public authorities should have any jurisdiction 
over the patient or his treatment, would make possible a body of informa- 
tion of the utmost importance. 

Education of the public in the preventable and curable aspects of 
cancer and in the necessity of personal alertness and attention to warning 
signs and symptoms of the early stages of cancer, might properly be 
undertaken as part of any broad program of public education in health 
and its protection. 

From the point of view of the sick cancer patient, San Francisco has 
not met her obligations, or shall we say, her opportunities for service. 

Hospital beds for inoperable cases of cancer are almost unobtainable, 
and especially for the poor. Definite provision at the San Francisco and 
other general hospitals might be made in the medical or surgical wards for 
cancer patients for whom home care is impracticable. 



Services for Health and Its Protection 25 

When there is a visiting nurse service throughout the city, it will 
probably be found that large numbers of cancer patients are in need of 
attention whose miserable state at present is only relieved by death. 
Hospital care in homes for incurable disease is a humane service which 
would meet the needs of those for whom the general hospitals or home 
nursing are inappropriate or impractiable. 

It would seem that the problem of cancer is worthy of separate and 
special consideration by a sub-committee of such a Health Council as is 
suggested. 

PERIODIC HEALTH EXAMINATIONS 

It will have been noticed in the reading of the preceding text dealing 
with the larger problems of preventive medicine that the essential for pro- 
tective as well as for curative medical service is a thorough medical 
examination. To an increasing degree those planning well-proportioned 
campaigns for disease prevention at all ages, realize the dependence of 
every phase of the work upon examination of apparently healthy persons, 
at such intervals as will secure a continuance of health, and give a sound 
basis for individual advice in avoiding such errors of habit, conduct, or 
exposure to disease, or the effects of advancing years, as commonly inter- 
fere with health. 

In addition to the emphasis necessarily placed upon such health ex- 
aminations by those particularly interested in tuberculosis, child hygiene, 
heart diseases, etc., a truly impressive contribution to the health of the 
community would result from the adoption of a policy on the part of 
every institution and agency, public or private, co-operating under the 
Council of Social Agencies, or the Community Chest, whereby every mem- 
ber of the staffs and directing bodies should have an annual health exami- 
nation, preferably by their own family physician. Such an example would 
not only add materially to the health assets in terms of years of fruitful, 
happy work, and enjoyment of life of those engaged in community service 
of many kinds, but it would go far to develop the habit of such a pre- 
caution throughout the population. 

Such a personal annual health stock-taking at the hands of a competent 
physician is the least that any individual can do to contribute to his own 
and the community's health. 

In the realm of social and relief work, intelligent, constructive family 
case service cannot be given unless there is a thorough medical examination 
provided for each member of the family before final decision is reached 
regarding the provision for individual or family rehabilitation. 

The importance of medical health examinations has recently received 
especial endorsement from the American Medical Association and from the 
member associations of the National Health Council. The necessity of a 
public facility for health examinations of dispensary clientele, and for the 
teaching of medical students, has been recognized by the University of 
California Medical School in the proposal to establish a health clinic at 
the University of California Hospital dispensary in the immediate future. 



26 Hospital, and Heai/th Survey 



A SAN FRANCISCO HEALTH COUNCIL 

The Committee on Hospitals and Health Agencies of the Council of 
Social and Health Agencies of San Francisco is charged with the same 
kind of double function which has been criticized above in the considera- 
tion oi the Board of Health and its direction of the San Francisco Hos- 
pital and the Department of Public Health. 

It will appear reasonably clear from a reading of the facts presented in 
Section III that the care of the sick by hospitals and dispensaries is sus- 
ceptible of great improvement, from the point of view of quality, quantity 
and costs. There have been presented above brief discussions of a few r 
of the more important public health problems of San Francisco, with here 
and there a suggestion that study and planning must be undertaken seri- 
ously if accomplishment is to keep pace with the established facts of 
science and the reasonable desires of good citizenship. 

These two truly great fields of human endeavor, namely, to give the 
best of care to the sick, and to develop and protect health, though closely 
bordering upon each other at many points, are so different in their content 
that they require quite separate and distinct groups for their analysis and 
promotion. 

If the Committee on Hospitals and Health Agencies should resolve 
itself into two groups, one possibly called a Hospital Council and serving 
functions described in some detail in Section III, the other a Health 
Council devoted to the study and development of such projects as have 
been dealt with above in Section II, both types of public service would 
receive much needed stimulation with a promptness not otherwise likely. 

If such a group or council, devoted to the health problems of the com- 
munity, were created from among the considerable number of competent 
and public spirited men and women interested and professionally trained 
in one or more of the aspects of health protection, who are now available 
in San Francisco, they would require a permanent paid secretary to be 
their executive officer, not simply to carry on office correspondence, but 
to assemble facts, make original inquiries into the work of health agencies 
and prepare matters for the consideration of the various sub-committees 
which would be held responsible for the formulation of programs or 
recommendations. 

Sub-committees would be called for and appointed from those with- 
out as well as w T ithin the membership of the Health Council, according 
to the changing needs from year to year, but in all probability for a long 
time to come there will be a use for standing committees devoted to such 
leading subjects as have already enlisted much public support. There might 
well be committees on : Public Health Education, Health Department Prac- 
tice, Child Hygiene, Mental Hygiene, Cancer, Heart Disease, Social 
Hygiene and Visiting Nursing. 

The San Francisco Tuberculosis Association would be to all intents 
and purposes the committee on tuberculosis of such a Health Council. 



SECTION III 

Services for the Sick 

While care of the sick in bed in hospitals, or the walking patient at 
the dispensary, may have expressed the full conception of service in this 
field in the past, at present the vision of curative and preventive medicine 
calls for other institutions better suited to the needs of certain groups of 
invalids, and for the collaboration of the professions trained to teach health 
and to complete medical care by social assistance. 

The best that can be provided for the patient with ample means, by 
the attention and continuous guardianship of the private practitioner of 
medicine, is more and more found to be practicable for the wage earner 
and the dependent family, through the correlation of services offered by 
public or privately supported agencies. 

Without attempting to outline the entire range of institutions and 
organizations which may at one time or another be called upon to 
assist in the process of re-establishing the sick in health of body and mind, 
it has been considered by this Survey that in addition to Hospitals and 
Dispensaries, recognized as public services of much importance to the 
safety and comfort of the community, the following auxiliary or inter- 
locking agencies are similarly essential : The Visiting, Public Health or 
District Nurse Association, Medical Social Service, Convalescent Homes, 
and Homes for Incurable or Chronic Invalids. 

All of these agencies, through the suitable co-operation of which the 
sick are helped to regain health, or to prolong life without unnecessary 
suffering or disability, are so intimately related to each other in any com- 
plete plan for modern service to the sick, that the adequacy of each in a 
community must be studied before recommendations can be offered for 
changes or extension of any of the others. 

HOSPITAL PROVISIONS AND COMMUNITY NEEDS 

In studying the particular place filled by a group of hospitals, it is 
necessary to picture them in relation to the total hospital facilities and 
to appraise their contributions in connection with the generally accepted 
standards of hospital service. 

San Francisco has nineteen hospitals exclusive of those maintained 
for the convalescent, insane, incurable, aged and infirm. As in other 
cities, these represent two general types of institutions: (a) those hospitals 
which have been gradually built up by voluntary effort or public taxes 
for the community as a whole, and (b) proprietary institutions which, 
growing up spontaneously as business enterprises, furnish service for the 
sick comparable to that of the private school in the field of education 



28 Hospital and Health Survey 

which serves only special social, religious or economic groups or a clientele 
limited by trade, occupation, race, etc. 

The following table indicates the hospital accommodations under public 
and private control, and of the latter, those which accept funds as charitable 
institutions, and those which are maintained as commercial enterprises: 

Hospital Facilities of San Francisco* 
Public Institutions 

Beds 

San Francisco Hospital (supported by City Taxes) 893 

University of California Hospital (supported by State Taxes) 282 1175 

Privately Controlled Institutions 

Accepting Funds as Charitable Institutions — 

Children's Hospital 275 

Franklin Hospital 214 

French Hospital 200 

Lane and Stanford Hospital 314 

Mary's Help Hospital 147 

Mount Zion Hospital 150 

Shriner's Hospital 50 

St. Joseph's Hospital 202 

St. Luke's Hospital 141 

St. Mary's Hospital 166 1859 

Maintained as Commercial Enterprises — 

Dante Sanatorium 65 

Florence N. Ward Hospital , 50 

Hahnemann Hospital 112 

Morton Hospital 100 

Southern Pacific Hospital 250 

St. Francis Hospital 325 

Union Plant and Alameda Works Hospital 

(Bethlehem Shipbuilding Corporation) 24 926 

Total 3960 

None of the privately supported hospitals accepting voluntary contribu- 
tions as charitable undertakings, receive public funds, there being in San 
Francisco no system of public subsidy for the care of the indigent sick in 
other hospitals than those maintained by taxation. With the exception of 
two institutions, which have not applied for appropriations from the Com- 
munity Chest, all of the private charitable hospitals receive Chest support. 
The two exceptions in question are the Shriners' Hospital, the main public 
activity of the Sacred Order of the Mystic Shrine, furnishing free hospital 
care to children from the extreme Western States, suffering from ortho- 
pedic disabilities, and St. Joseph's Hospital, which is conducted by the 
Sisters of St. Joseph, and. which, furnishing care chiefly to full-pay 

*The following for various reasons are not included in the general hospital facilities 
of the community: Polyclinic Hospital, 12 beds; Molony's Hospital, 10 beds; and St. 
Peter's Hospital, 5 beds. 



Services for the Sick 



29 



patients, has not as yet requested funds to meet the care of the free and 
part-pay service furnished. 

The nineteen hospitals listed include those for both general and 
special cases of an acute and chronic nature, the special institutions re- 
ceiving only such patients as are suffering from a particular type of 
disease or disability. Since certain of the facilities are thus available only 
for special conditions, the adequacy of the hospital accommodations of 
the city is dependent upon the distribution of the 3960 beds, according to 
the various medical services. These facts are shown in the following 
table : 

Distribution of Hospital Beds by Medical Service 









CJ r»n f^y 


al Services 
Obstet- 
rical 






Communicable 
Disease Services 
Tuber- All 
culosis Others 


Total 
Beds 


Total 
Gen'l 
Beds 


Medi- 
cal 


Surgi- 
cal 


Pedi- 
atric 


Used ^ 
Inter- 
change- 
ably 






Public Institutions 








San Francisco 893 


523 


181 


256 


27 


59 




250 120 


University of 
California. . , 282 


282 


79 


105 


30 


68 




• • • • • • 



Totals ....1175 805 260 



361 



57 127 - 



250 



120 



Privately Controlled Institutions 



Accepting Funds as Charitable Institutions — 



Children's . . . 


275 


249 




44 


34 


75 


96 


Franklin 


214 


214 






10 




204 


French 


200 


200 


• • * 


• « a 




• • • 


200 


Lane and Stan- 
















ford Univ. .. 


314 


314 


54 


51 


21 


35 


153 


Mary's Help . 


147 


147 


. . 


• • • 


30 




117 


Mount Zion . . 


150 


150 


24 


24 


5 


12 


85 


Shriner's 


50 


50 




50 








St. Joseph's .. 


202 


202 


68 


107 


27 






St. Luke's . . . 


141 


141 




• • • 


11 




130 


St. Mary's . . . 


166 


166 


• • • 


. . . 


16 


• • • 


150 



Totals 1859 1833 146 



276 



154 122 



65 



Maintained as Commercial Enterprises — 

Dante Sanator- 
ium 65 

Florence N. 

50 
112 
100 
325 
24 
250 



1135 



65 



26 



26 



Ward 
Hahnemann 
Morton .... 
St. Francis , 
Union Plant 
So. Pacific . 



50 
112 
100 
325 

24 
250 



10 



Totals 926 926 



10 



Grand Tot'ls 3960 3564 416 



• • • 


• • • 




50 


• • • 






112 


80 


10 






• • 


• • • 




325 








24 


. . . 


. . . 




250 


80 


10 


• ■ • 


826 


717 


221 


*249 


1961 



250 



146 



♦This total includes 114 cribs for new-born infants, as new-born are assigned to the 
pediatric services in a few of the hospitals. 



30 Hospital and Health Survey 



Experience indicates that a provision of five general hospital beds for 
each thousand of population is needed to afford adequate facilities for 
the hospitalization of general medical and surgical conditions, maternity 
patients and children. In addition, there are needed, for the acute com- 
municable diseases, five beds for each ten thousand of population,, and 
for the tuberculous, as many beds as there are deaths in the year from 
tuberculosis. 

It has been found in the larger cities of the country that the ratio of 
live beds for general medical and surgical patients per thousand of the 
population should include five beds per 10,000 persons for children, and 
forty-five beds per 100,000 to hospitalize 30 per cent of the maternity 

patients. 

Based upon the foregoing, San Francisco, with a population of 540,000 
should have, as a minimum, 2700 general hospital beds, 270 beds for acute 
communicable diseases, and 500 beds for tuberculosis. 

It is evident that, with 3564 general hospital beds available, affording 
6.6 beds per thousand of population, there are sufficient facilities to meet 
this minimum of the city's needs. 

In considering the question of ratio of beds to population, however, it 
should be borne in mind that the hospitals serve a much larger area than 
the general metropolitan district. Due to the city's prominence as the lead- 
ing medical center of the Pacific Coast, patients come from distant sec- 
tions of the State and from outside of the State, to take advantage of the 
superior facilities available for diagnosis and treatment. For example, the 
University of California receives patients from the entire State, several 
other of the institutions — the Southern Pacific Hospital and the Shriners' 
Hospital — accepting patients from neighboring States as well. 

The extent to which non-residents use the hospitals was indicated by 
the Survey's analysis of the places of residence of some 6000 patients 
admitted to ten of the hospitals (representing 70 per cent of the total 
hospital facilities) during November, 1922, and January, 1923. As this 
study showed that 16 per cent of the patients were non-residents of San 
Francisco, it is believed that the true minimum number of general beds 
should be not less than 2970, that is, at least 10 per cent more than the 
minimum for the city's population alone. 

The birth rate of the population of San Francisco is not over 16 per 
thousand of the population, and the practice of the people of San Fran- 
cisco is to hospitalize at least 65 per cent of their maternity patients — the 
percentage hospitalized increasing steadily in recent years. It is suitable, 
therefore, in determining the number of beds needed for maternity care 
under the general heading of beds for medical and surgical patients, to 
alter estimates appropriate for industrial cities in the Eastern United 
States, where the birth rate is 20 per thousand of the population or over, 
and where experience shows that rarely more than 30 1 per cent of mater- 
nity patients are cared for in hospitals. 

Instead, therefore, of providing for an estimated 30 per cent of the 



Services for the Sick 31 



8557 births reported in the twelve months ending June 1, 1923 — 2567 — by- 
setting aside 128 beds, that is, one bed for each twenty such hospital 
patients a year, San Francisco should provide hospital beds for not less 
than 75 per cent of the births, or 320 beds. As this is 77 beds more than 
the number required to hospitalize 30 per cent of the maternity patients 
on the population basis (243 beds), the total minimum desirable beds is 
thus raised from 2970 to 3047. 

Based upon these accepted ratios we have thus, all told, a theoretical 
need in San Francisco for the 540,000 population and non-residents, as 
follows : 

Beds 

1 — General Medical and Surgical Conditions 3047 

(a) Children 270 

(b) Maternity 320 

(c) Others 2457 

2 — Acute Communicable Diseases 270 

3 — Tuberculosis 500 

By consulting the table of hospital facilities on page 29, it will be seen 
that the accommodations available for the foregoing groups are: 

Beds 
1 — General Medical and Surgical Conditions 3564 

(a) Children 135* 

(b) Maternity : 221 

( c ) Others 3208 

2 — Acute Communicable Diseases 146 

3 — Tuberculosis 250 

Comparison of the available and the theoretical facilities indicates that, 
although for the general medical and surgical conditions there are over 
500 more general beds than the suggested minimum, the facilities for chil- 
dren are one-half and those for maternity patients one-third less than the 
estimated need. 

The provisions for the acute communicable disease, while 124 beds 
less than the theoretical requirement, appear adequate, due to the low 
hospitalization of such conditions. In view of the foregoing, and as there 
are 150 beds available in case of need in the old Isolation Hospital, there 
is no apparent present shortage of facilities for this patient group. 

The facilities for the tuberculous show a serious shortage. If we 
include the preventoria accepting active tuberculosis cases, there still 
remains a shortage of 150 beds for this important specialty, as presented 
in detail earlier in the report. 

To sum up — Compared with the experience of other cities, San Fran- 
cisco has : 

(a) Ample beds for the general medical and surgical services, although 
there is an insufficient number of beds specifically equipped and set aside 

* Exclusive of 114 beds for new-born infants. 



32 Hospital and Health Survey 



for the care of children, and an insufficient number assigned to maternity 

patients. 

(M Sufficient facilities for communicable diseases in view of the lim- 
ited use of hospitals for the isolation of the common communicable dis- 
eases. 

(c) Need for from 150 to 250 additional beds for tuberculosis. 

Chapter i 

HOSPITALS 

The hospitals receiving the more special attention of the Survey 
included the nine institutions which are receiving or have applied for funds 
from the Community Chest and the San Francisco Hospital, which was 
studied only in so far as its activities relate to the hospital and health 
problems studied. The ten hospitals are : 

Hospitals Included in Survey 

Beds 
Public Institutions — 

San Francisco Hospital . 893 

University of California Hospital 282 1175 

Privately Controlled Institutions — 

Children's Hospital . 275 

Franklin Hospital 214 

French Hospital 200 

Lane and Stanford University Hospital 314 

Mary's Help Hospital 147 

Mount Zion Hospital ' 150 

St. Luke's Hospital 141 

St. Mary's Hospital ' 166 1607 



Total 278 



The importance of these institutions as major community activities is 
indicated by the fact that, combined, they constitute 70 per cent of the total 
hospital facilities of the city. As a group, during 1922, they cared for 
approximately 50,000 patients and furnished 630,000 days of treatment. In 
addition those that maintain dispensary departments furnish 87 per cent of 
the total hours of dispensary service of the city, and, during 1922, received 
approximately 252,000 visits — 90 per cent of the total number of visits. 

The location of these institutions, together with the volume of service 
rendered to bed patients and out patients, is shown in Map 1 on the oppo- 
site page. 

As medical agencies, they provide 94 per cent of the facilities defi- 
nitely assigned to the various medical services, there being practically no 
formal distribution of beds in the other hospitals of the city. The magni- 




PL, 
< 



N V 3 3 O 



J I J I J V cl 



34 Hospital and Health Survey 



tudc of their activities is reflected in their finances, as combined, they rep- 
resent a total estimated investment of over $11,000,000, with annual expen- 
ditures amounting* to over $3,700,000. 

Although eight of the hospitals are privately controlled, their large 
contributions to the community's welfare indicate that they occupy a posi- 
tion similar to that of public service corporations — organizations which, 
though privately owned and directed, minister to the common welfare by 
supplying community needs. The extent to which they supplement tax- 
supported facilities is shown in the fact that, as a unit, they furnished 16 
per cent of the free bed care during 1922, and 75 per cent of the bed care 
of patients who paid only part of the cost of hospital service. 

Their relation to the Community Chest may be briefly stated: 

Of the two hospitals supported by taxes, the San Francisco has made 
no application for funds collected by the Chest, the University of Cali- 
fornia, through its Auxiliary, concerned with out-patient and social service 
activities, receiving $6000 for 1923. In addition, the last-named institution 
has applied directly for funds for bed care. 

Six of the privately supported institutions receive Chest funds, one of 
them. Lane and Stanford University Hospital, receiving funds through the 
Stanford Clinics Auxiliary and San Francisco Maternity* the organization 
maintaining the hospital's Social Service Department. In addition, appli- 
cations for participation in Chest funds are pending for the French, Lane 
and Stanford University, and St. Mary's Hospitals, 

The amounts allocated to the several hospitals for 1923, in each 
instance corresponding to the amount obtained from charitable sources in 
recent years, are as follows : 

Children's Hospital , . $ 87,000 

Franklin Hospital 15,000 

Mary's Help Hospital 12,000 

Mount Zion Hospital 85,000 

St. Luke's Hospital.... _ 20,000 

Stanford Clinic's Auxiliary and San Francisco Maternity 12,227 

University of California Hospital Auxiliary 6,000 

Total $237,227 



ORGANIZATION AND ADMINISTRATION 

To accomplish their common end — "to care for the sick," "to aid the 
sick and suffering," "to give medical care and comfort to the sick," "to 
assist in medical education," "to train nurses," etc.— various types of gov- 
erning boards have been set up with more or less well-defined organiza- 
tions, committee activities, and administrative policies. 

Of the two publicly supported institutions, the San Francisco Hospital 
is directed by the Board of Health, a combined lay and professional board 



Services for the Sick 35 



of seven men serving without remuneration. The Board meets weekly, and 
has finance, hospital, and building committees with definite responsibilities, 
and receives frequent and detailed reports of certain of the institution's 
activities. As it also directs all of the other activities of the Board of 
Health, it is not exclusively the managing board of the hospital. 

Experience has demonstrated that the operation of a hospital is best 
served by a board whose sole function is the direction of the institution. 
The manifold responsibilities carried by the Board of Health and the 
diversified activities which it directs suggest a need for a specially 
appointed group, such as a board of trustees, to which it could delegate 
the responsibility of the direction of so important an undertaking as the 
hospital, the largest in the city and caring for the greatest number of 
patients. Other cities are adopting this method of meeting the special 
needs of municipal hospitals. For example, the Cleveland Hospital Council 
has recently made formal recommendations to the Cleveland City Council, 
urging the appointment of a board of trustees for the Cleveland City 
Hospital. 

The University of California Hospital, directed by the Board of Re- 
gents of the university, is likewise but one of many activities receiving 
the attention of the regents. The committees of the Board, comprising 
Agriculture, Conference with Faculty, Educational Relations, Endowments, 
Engineering, Executive, Finance, Grounds and Buildings, Jurisprudence, 
Letters and Science, Library, Research and Publications, Lick Observatory, 
University of California Medical School, Southern Branch of the Univer- 
sity of California and Scripps Institution for Biological Research, and Wil- 
merding School Committees, makes no special provision for the direction 
of the hospital's affairs. 

It is the general sentiment in present day hospital operation that the 
lack of a directing group, whose sole function is the operation of a hos- 
pital, deprives both the staff and the hospital administration of a highly 
desirable contact with the responsible, policy-forming body. 

The hospital is an institutional member of the American Hospital 
Association, and publishes no annual report. 

The Hahnemann Hospital (not included among the hospitals studied 
in detail in this Survey) , formerly the Homeopathic Hospital and acquired 
by the university in recent years, is maintained by the regents as a general 
hospital for private and industrial cases. The present policy, which appears 
to take small account of the medical standards at this institution, is judged 
unsuitable and unworthy of so responsible a board as the regents of the 
university. The hospital is more like a stepchild than a member of the 
university family, as regards its medical standards and administrative 
procedures. 

Brief mention may be made of the directing organization of the eight 
privately controlled institutions : 

Children's Hospital — The Children's Hospital, incorporated in 1875, 
for the exclusive care of sick women and children, the education of women 



36 Hospital and Heai/th Survey 



physicians, and the training of nurses, has a Board of Trustees consisting 
of five men which meets monthly and is concerned only with the finances 
of the institution. The direction of the hospital is centered in a Board of 
Women Managers of thirty, which meets monthly with an average attend- 
ance of two-thirds of its membership. The committees are Executive, 
Finance, Joint, Conference, Admissions, Social Service, Training School, 
Housekeeping, and Building. The reports considered by the Board of 
Managers relate to all hospital departments and to all committee activities. 
Although the committee organization of the board provides for committee 
supervision of specific activities, it is evident that many committee func- 
tions are administrative rather than directing, and that the personnel of 
some committees is not sufficiently comprehensive. 

The Conference Committee, a joint committee of the board and medi- 
cal staff, is comparatively recent and in line with present-day methods of 
establishing contact between directing and professional groups. At the 
time the institution was visited, the board had not required of its staff the 
usual monthly clinical conferences, nor was there any program for staff 
review of the medical work of the hospital. The Training School and 
Social Service Committees do not include all the advisable elements in their 
membership, and there is no Dispensary Committee, although the hospital 
operates a dispensary department. 

The Board of Trustees has not so directed the hospital's finances that 
budgetary methods are used or that a financial plan is in effect. 

The board, conducting a notable service to the community and holding 
large funds entrusted to its use for the care of the sick poor, has published 
no annual report since 1918. The institution has no- national hospital 
memberships. 

Franklin Hospital — The Franklin Hospital is maintained by the Ger- 
man General Benevolent Society, an incorporated insurance association, 
founded in 1854, to provide relief to men, women, and children of German 
origin and to maintain a medical organization and hospital for the benefit 
of its members. The activities of the Society are directed by a Board of 
Directors which meets monthly, the hospital being supervised by a Hospital 
Committee which meets bi-monthly. These two groups receive bi-monthly 
reports of finances and the activities of the hospital and the Society. The 
activities of an auxiliary committee composed of women are limited to the 
relief of beneficiaries of the Society living in their homes. The board lacks 
the indicated organization for the direction of hospital activities as the 
usual committees such as executive, finance, training school, etc., have 
not been established. The institution has no national hospital member- 
ships. The annual report of hospital activities is contained in the Society's 
report and consists of a rather complete financial statement, but only 
brief statistical hospital material. The attending staff holds monthly clinical 
meetings, but as the board does not require complete medical histories, 
the review of the medical work is not complete. 

French Hospital — The French Hospital, maintained by the French 
Mutual Benefit Society, did not furnish the Survey with the needed infor- 



Services for the Sick 37 

mation regarding organization, administration, finances, etc., the only mate- 
rial furnished relating to the number of patients and days of care for 1921 
and 1922. The annual report of the Society indicates that the hospital, 
founded in 1852, is maintained to furnish hospital care to medical and sur- 
gical cases and to members of the mutual benefit association. The Society 
is governed by an Administrative Council of fifteen, with the usual officers. 
Details as to committee organization and function, hospital memberships, 
etc., are not known. The Society's annual report does not segregate hos- 
pital and Society income and expenditures, and presents only a meager 
picture of the institution's activities. 

Lane and Stanford University Hospital — Lane and Stanford Univer- 
sity Hospital has been maintained by Leland Stanford Junior University 
for a little over ten years as an incorporated department of the uni- 
versity. The hospital's affairs are directed by a Clinical Committee com- 
posed of four members of the Medical School faculty and the physician 
superintendent of the institution. The committee meets monthly, has the 
usual officers but no sub-committees, and receives complete and detailed 
monthly reports. There are no auxiliary committees to the Clinical Com- 
mittee, although the Stanford Clinic Auxiliary and San Francisco Mater- 
nity, which maintains the Social Service Department, is in effect an aux- 
iliary to the hospital's directing group. 

As in the case of the two publicly supported hospitals, it is judged 
that the best interests of this institution will be served by the establishment 
of a lay board of trustees, which includes women members. The present 
organization of the institution — the hospital conducted by one group, the 
Out-Patient Department conducted by the Medical School and the Social 
Service Department conducted by a group with no formal connection with 
the hospital — provides separate direction and financial responsibility of 
activities which are essentially administrative departmental units of the 
hospital. 

The hospital has no national memberships. It publishes an interesting 
and rather full annual report of hospital activities, exclusive of finances, 
containing brief hospital statistics and analyses of use, and presentations 
of the activities, needs and new objectives of most of the medical depart- 
ments. The Stanford Clinics Auxiliary and San Francisco Maternity pub- 
lishes a separate report of the work of the Social Service Department. 

Mary's Help Hospital — Mary's Help Hospital, maintained by the Sis- 
ters of Charity for the care of the sick poor, was incorporated thirty years 
ago and is governed by a Board of Directors of six men which meets 
monthly. The board has a president and secretary, and reviews financial 
and statistical reports monthly, but functions without committees. The hos- 
pital has no national hospital association memberships, and publishes no 
annual report. 

Board organization of this limited character is no longer advocated in 
Sisters' hospitals. Experience indicates that the interests of such hospitals 
are better served by a board composed of lay men and women, members 
of the Sisterhood conducting the hospital, and representatives of the Catho- 



38 Hospital and Health Survey 



lie clergy. Boards thus constituted are in successful operation in other 
sections of the country, and have been found more effective in establishing 
close contacts with the community than the smaller boards consisting of 
men or Sisters only. 

St Mary's Hospital — St. Mary's Hospital, founded in 1855 to care for 
the sick, train nurses, and instruct students in medicine and surgery, is 
conducted by the Sisters of Mercy and governed by a board of four Sisters 
which meets monthly. The board has one committee, on finance, which 
also meets monthly and submits financial reports. As previously men- 
tioned, this type of organization is less effective in meeting community 
health needs than the larger boards constituted as outlined. A women's 
auxiliary recently organized to assist with a dispensary department, which 
is in process of establishment, has as yet no definite functions. 

The hospital is a member of the Catholic Hospital Association. No 
annual report has been published since 1920. 

Mount Zion Hospital — Mount Zion Hospital, incorporated in 1847, 
primarily to serve the Jewish sick of the city, is governed by a Board of 
Directors of seventeen which meets monthly, has the usual officers and 
rather elaborate committee organizations, including Executive, Purchasing, 
Kitchen, Diet-Kitchen, Laundry, Linen room, Dispensary, Social Service, 
Finance, Pharmacy, Laboratory, X-ray, and Building and Grounds. Mem- 
bers of the Ladies' Auxiliary, an unofficial group active in hospital work, 
serve on many of the committees, in some instances constituting the entire 
committee personnel. Committees meet monthly and submit reports to the 
board through the Executive Committee. The committee organization sug- 
gests that committees participate in administrative activities. Neither the 
Committee on Nurses nor the Dispensary or Social Service Committees are 
organized along the lines considered appropriate for their respective respon- 
sibilities. An unusual committee is the Medical Conference Committee 
composed of members of the staff, department heads and board officers, 
which functions as a policy-making body in medical matters. 

Members of the Ladies' Auxiliary also serve on many of the com- 
mittees and as workers in the Social Service Department. The organiza- 
tion as a whole suggests considerable activity both on the part of the board 
and of the auxiliary. The institution has no national hospital association 
memberships. A brief report of its activities is contained in the annual 
report of the Federation of Jewish Charities. 

St. Luke's Hospital — St. Luke's Hospital, founded in 1871 to care for 
the sick, is governed by a Board of Directors of nine men and two women 
which meets monthly and has, in addition to the usual board officers, a 
combined treasurer and auditor. The committees of the board are : Execu- 
tive, Investment, Training School, Social Service, and Dispensary. Of the 
foregoing, the Executive Committee alone meets regularly. The other com- 
mittees meet only on call, and do not include the personnel regarded as 
advisable for effective board contact with hospital matters. The board does 
not review^ the usual reports considered essential for the guidance of the 
governing body of a hospital. Lacking reports of work done and a com- 



Services for the Sick 39 



mittee organization, there appears to be insufficient contact with hospital 
affairs. The hospital is an institutional member of the American Hospital 
Association and publishes a report annually, which, among other matters, 
contains a complete financial statement and a less detailed statistical and 
medical report. An auxiliary committee, called the Women's Board, 
appears to function largely in rendering voluntary assistance. 

Comment 

So brief a summary of general policies does not depict the many indi- 
vidual excellencies of organization and direction which exist, nor does it 
convey a true impression of the instances of devoted and sympathetic 
interest which characterize so much of the hospital service. 

It is by no means uncommon in hospital affairs to find that the per- 
sonal attention, good-will, and generous interest of board members are 
hampered by poor organization, incomplete provisions for committee activi- 
ties, and ineffective means for reviewing the results achieved. 

An important development in the hospital world is that boards are 
finding it advisable to effect changes in types of directing organization 
which, though formerly satisfactory, are today unsuited to meet the 
demands of modern hospital operation. 

The directing groups of the ten hospitals would gain by a critical 
self-analysis of the adequacy and suitability of their individual organiza- 
tions for the administration of their respective trusts. It is clear that there 
is need for a greater familiarity with many principles of board organiza- 
tion, committee functions, public reports, etc., which are advocated by 
leading hospital boards, administrators, and national hospital associations. 

It is proper that attention be directed to the fact that the three most 
prominent hospitals, both as to size and leadership — the San Francisco, 
University of California, and Lane and Stanford University Hospitals — 
lack boards so widely representative and thoroughly organized as to permit 
the type of intensive study and direction of these great public utilities 
which their complexity, cost, and importance demands. 

. SERVICES RENDERED BY HOSPITALS 

In learning the extent of the community service rendered by a group 
of hospitals, we measure both individually and collectively, (a) the degree 
to which the facilities are used, (b) the hospital care given to full-pay, 
part-pay and free patient groups, (c) the medical services offered, and 
(d) the areas and the sections of the population served. 

The facts herewith presented relating to these factors of service for 
the ten hospitals are based on the experience of 1921 and 1922, assembled 
by the institutions for the Survey, the data collected on June 21, when a 
census was taken of hospital patients, information collected at the hospitals, 
opinions and facts furnished by physicians and medical and social agencies, 
facts contained in published hospital reports, information collected by 
visits to 160 patients discharged during the first three weeks of June, and 



40 Hospital and Health Survey 



an analysis of the places of residents of the 6542 patients admitted to the 
hospitals during two representative months — November, 1922, and January, 
1^23. 

(a) EXTENT OF USE OF HOSPITAL BEDS 

The unit of measurement of hospital use is the care of one bed patient 
for one day, the extent of use being indicated by the comparison of the 
number of days' treatment furnished in a given period, with the number 
of days' treatment available in the same period. For example, a hospital 
of 100 beds with 36,500 days available yearly, if actually furnishing 30,000 
days, uses 82 per cent of its potential facilities. 

Hospital authorities estimate, allowing for renovations, repair of wards, 
quarantine, and seasonal fluctuations in demand, that a general hospital 
should use an average of 75 per cent of its available days of care for a 
year as a whole, and that over 80 per cent of use should be expected 
during the busier portions of the year. 

A degree of use of less than 75 per cent is commonly due to one or 
more factors, (a) overbuilding; that is, more hospital beds than are actually 
needed, (b) unsuitable distribution of facilities for the several patient 
groups, and (c) defective administration. 

When an institution shows 85 per cent of use or more, it is generally 
taken as an index that the demand for beds exceeds the supply, and that 
the administration of the hospital is effective. 

If each of the 2782 beds in the ten institutions was used every day 
of the year, they could furnish a total of 1,005,210 days of care, but such 
a performance would be impracticable in hospital administration and is 
unknown in the experience of general hospitals for acute sickness. 

The percentage of use during the past two years for the institutions as 
a group, including the facilities for tuberculosis and acute communicable 
diseases, was : 

Use of Hospital Facilities, Including Tuberculosis and Communicable Diseases 

1921 68% (685,778 days) 

1922 71% (714,659 days) 

The exact percentage of use of the general hospital beds is not known, 
due to the fact that the San Francisco Hospital could not furnish the days 
of treatment of the general hospital section apart from these data for the 
120 beds in the communicable disease department. 

The degree of use of the general hospital facilities for the past two 
years, as given below, includes both the general and communicable disease 
experience. The percentage of use of the 913,960 days of treatment thus 
available was : 

Use of Hospital Facilities, Tuberculosis Excluded 

1921 67% (608,434 days) 

1922 .69% (629,567 days) 



Services for the Sick 41 

During 1922 the hospitals cared for 51,811 patients, as follows: 

s 

Hospital Admissions — 1922 

Patients 
Public Institutions — 

San Francisco Hospital 7993 

University of California Hospital 4726 12,719 (25%) 

Privately Controlled Institutions — 

Children's Hospital 4873 

Franklin Hospital 3838 

French Hospital 2366 

Lane and Stanford University Hospital 8933 

Mary's Help Hospital 4071 

Mount Zion Hospital 4657 

St. Luke's Hospital 5960 

St. Mary's Hospital 4394 39,092 (75%) 

Total ." 51,811 

The individual experience of the hospitals expressed in days of care, 
presented in the following table and in Chart A, page 43, indicates the 
total number of days of treatment available, the actual number of days of 
treatment furnished, and the percentage of use these facts represent, for 
each of the ten institutions. 



42 Hospital and Health Survey 



Degree of Use of Hospitals — 1922 

Total Days Total Days Per Cent 

Bed Care Bed Care of 

Available Given Use 
Public Institutions — 

San Francisco r . . 234,695 158,027 67 

University of California 92,710 61,049 66 

Total 327,405 219,076 67 

Privately Controlled Institutions — 

Children's 100,375 60,128 60 

Franklin 78,110 54,813 70 

French 73,000 46,663 64 

Lane and Stanford University 114,610 79,138 69 

Mary's Help 53,655 34,379 64 

Mount Zion 54,750 44,147 81 

St. Luke's 51,465 39,457 76 

St. Mary's 60,590 51,766 85 

Total 586,555 410,491 69 

Grand Total 913,960 629,567 69 

As shown in the foregoing table, neither of the two tax-supported 
hospitals, and but three of those receiving voluntary contributions — St. 
Mary's, Mount Zion, and St. Luke's Hospitals — attained 75 per cent or 
more of use ; the remaining five showing 60 to 70 per cent of use. 

In order to ascertain the facts regarding possible periods of maximum 
and minimum demand for hospital care, a further detailed analysis was 
made of the percentage of use of the combined hospitals throughout a 
twelve-month period. The result of this analysis, showing the percentage 
of use by month for seven* hospitals is as follows : 

Per Cent of Use of Combined Hospital Facilities by Month — 1922 

(Seven Hospitals) 

Per Cent 
of Use 

January 69 

February 71 

March 71 

April 69 

May 65 

June 67 

July 67 

August 67 

September 64 

October \ 68 

November 68 

December 68 

Average for year, 69 per cent. 



*The San Francisco, Mount Zion and St. Luke's Hospitals could not furnish these 
data. 



CO 

-J 

< 



CL 
CO 

X <° 

-z. & 

Ld ~" 
H I 

— O 

UJ o 
CD ^ 
. < 

u. a: 
o u. 

uj z: 
co < 

z> co 

U. u. 
O o 

Ld 
UJ 

cr 
O 

UJ 

o 



o 
o 



o 



CO 



o 



3 



O 

10 



o 



O 
CO 



o 






(9 



^1 






<0 IN. 



5 

0> 



00 



CO 






o 



O) 



<0 



o 
o 



o 
(J) 



LP 

0- 



o 

00 



«0 



t» 



s 



o 
<0 



<0 



N 









l» 



* 






S 






I 

t© 



to 

If 



2 

to 
to 



t\l 
cT 



3 

to 



I 

£ 



to 

to 



5 






to 

>* 

ro 



t»> 



5 



o 






o 
^- 



o 



8 



o 



o 



< 



o 



O 



h* 



f> 


c 
o 


U) 




<5 

z 


M 

■4- 
C 

O 

51 


*> 

0) 

D' 


c 

IS 

C 



* 



• oj c 

lit! 



3 Z 



o 

C 

Q) 

. ft. 



C 
ft. 

-X 



44 Hospital and Health Survey 



This experience for the twelve-month period, also shown in Chart B, 
page 45, while based on but 40 per cent of the city's hospital facilities, pre- 
sents so slight a seasonal variation that it is probable that the experience 
of the other institutions would be approximately the same. It is signifi- 
cant that in no month of the twelve-month period did the seven hospitals, 
as a group, show 75 per cent of use, the highest, 71 per cent, occurring 
in but two months, February and March, and the lowest, 64 per cent, in 
September. 

The degree to which the individual hospitals used their available num- 
bers of days throughout 1922 is shown in the following table, which thus 
indicates that, although as a group, the hospitals showed relatively slight 
variation in the extent to which the available number of days were used 
from month to month, there were considerable differences in the extent to 
which individual institutions were used throughout the year: 

Degree of Use of Individual Hospitals by Month — 1922 (Seven Hospitals) 

Children's Franklin French Lane and Mary's St: Univer. 

Stanford Help Mary's of 
Univer. Calif. 

Per ct. Per ct. Per ct. Per ct. Per ct. Per ct. Per ct. 

January 64 72 64 72 60 81 68 

February 64 77 65 73 86 79 59 

March 61 69 72 77 61 89 55 

April 62 65 67 64 77 81 77 

May 59 65 67 68 61 73 66 

June 55 71 64 67 75 73 59 

July 59 75 62 68 59 73 73 

August 62 71 58 68 71 69 68 

September 58 72 60 69 57 72 57 

October 80 78 58 71 57 78 64 

November 61 72 63 69 54 77 77 

December 69 66 65 71 57 81 64 

Thus, the percentage of use at the University of California Hospital 
varied during the twelve-month period from 57 to 77 per cent. In only 
two months, April and November, did the institution use 75 per cent or 
more of its potential capacity, four months, March, February, June and 
September, showing but 55, 57 and 59 per cent of use. 

The degree of use of the facilities at Lane and Stanford University 
Hospital showed somewhat less variation, with a minimum percentage of 
64 per cent in April, and a maximum of 77 per cent in March. 

The French Hospital facilities showed fluctuations in use from 58 to 
72 per cent, in no month attaining 75 per cent of use. 

The percentage of use at Mary's Help Hospital showed the widest 
variations of any of the institutions, with a maximum of 86 per cent dur- 
ing February and a minimum of 54 per cent during November, and with 
three of the months — February, June, and April — showing 75 per cent or 
more of use. 

The Franklin Hospital shows a fairly constant use, three months — 



o 
o 



o 

CD 



O 
00 



O 



o 

CD 



O 
LO 



o 



o 



o 
ai 



o 



o 



in 



C/3 


> 

o 


—J 


K 


< 




h- 




Q. 




CO 


k. 


O 


5 


X 




o 




o 




co 


§ 


—— 


</> 


o 




z 




< 




or 




b_ 


5 


z 




< 




^aj 


>5 


^ <y 


»■> 


LJ 0) 




> — 




U | 


Ul 


cQ ' 


z 


cQ 


3 


z x 




— H 




^ ^ 




Q O 


5 


Ld r 


2 


CD 




>- 




b_ CD 




O 


a 




a 


U 


< 


to 




Z) 




b_ 


g 


O 


i 


u 




o 




< 




\- 


ft 


z 




Ld 




O 




or 




LJ 
Q_ 


z 
< 



o 

ui 
o 



> 
o 

z 



0. 
ul 






oc 
a 

< 






E 



LO 
N 

_1_ 



O 

o 



o 

0) 



o 

00 



o 



o 

CD 



O 
L0 



? 



o 



O 
cvj 



o 



46 Hospital and Heai/th Survey 



February, Jul}, and October — showing 75 per cent or more of use, with 
the lowest percentage occurring in April and May, when 65 per cent of 
the facilities were used. 

St. Mary's Hospital shows a general percentage of over 75 per Cent 
of use and for four months, over 80 per cent. During March, the hospital 
was used to 89 per cent of its capacity, the highest percentage for any one 
month for any of the seven institutions. The lowest percentage, 69 per 
cent in August, was also the highest minimum for any of the hospitals. 

The Children's Hospital shows a fairly constant use of from 55 to 64 
per cent. While a children's hospital may show a generally low degree 
of use because of the emergencies, such as contagion, arising in their opera- 
tion which require that facilities be available when needed, although such 
a need may be infrequent, analysis of the very complete statistics assembled 
by this institution did not indicate that such was the case in this instance. 
The department for communicable diseases during 1922 used 22 per cent 
of its available days, the general hospital sections, minus the foregoing, 
showing but 64 per cent of use. Further analysis of the days of care fur- 
nished to special patient groups reflect a generally low use of the available 
capacity. Thus, the maternity department, with 12,410' days available, in 
1922 was used to but 59 per cent of its capacity. 

It is of interest that on June 21, on which day a census was taken of 
the patients in each hospital, 1805 of the beds available, exclusive of those 
for tuberculosis at the San Francisco Hospital, were in use. As shown in 
the following table, the percentages of use on this day do not differ mark- 
edly from those for 1922 as a whole : 

* Percentage of Use of Hospitals — June 21, 1923 

(Including Contagion) 

Number Number Per Cent 
Patients Beds of Use 

Public Institutions — 

San Francisco Hospital 428 643 69 

University of California Hospital 149 282 59 

Totals 577 925 62 

Privately Controlled Institutions — 

Children's Hospital 194 275 79 

Franklin Hospital 141 214 66 

French Hospital 130 200 65 

Lane and Stanford University Hospital 252 314 80 

Mary's Help Hospital 123 147 84 

Mount Zion Hospital 118 150 79 

St. Luke's Hospital 119 141 84 

St. Mary's Hospital 151 166 89 

Totals 1228 1607 70 

Grand Totals 1805 2532 71 



♦New-born infants and cribs for new-born are not included in estimating percentages. 



Services for the Sick 47 



The extent to which the hospitals are used suggests that the accommo- 
dations represented in this group of institutions afford ample facilities for 
the hospitalization of their patients, with possibly the exception of St. 
Mary's Hospital. The percentage of use of this institution reflects a con- 
tinuously high degree of use, and suggests a demand for additional 
facilities. 

(b) SERVICES FURNISHED TO PATIENTS OF DIFFERENT 

ECONOMIC GROUPS 

There are three standard classifications for grouping patients accord- 
ing to rate of payment; namely, full pay, those who pay the full cost of 
their care ; part pay, or those who pay part of the cost of their care, and 
free, those who pay nothing for their care. 

The total amount of free service rendered by a hospital is represented 
by a number of days for which no part of the cost was paid, plus the free 
service furnished to patients paying less than the cost of their care. 

In ascertaining this total amount of free service, the free care to part- 
pay patients is determined in conjunction with the per capita per diem 
cost, and the difference between the amount paid and the cost translated 
into terms of days. Thus, a hospital with a per capita cost of $4 a day, 
giving 200 days of care at the rate of $3 a day, and 100 days of care at 
$2 a day receives $800 for service which actually cost $1200, furnishing 
free care to the amount of $400 — the equivalent of 100 days of free care 
at the rate of $4 a day. 

Due to the small extent to which consideration of per capita costs 
enter into the assembling of data regarding part-pay patients in the hospi- 
tals, the Survey was unable to determine the actual amount of free ser- 
vice thus rendered. In consequence, the number of free days' treatment 
includes only the service received by patients paying nothing for their 
care. 

In addition, the material furnished the Survey indicated that in some 
instances part-pay patients, because they pay the rate charged, although it 
may be less than cost, are confused with pay patients. These facts should 
be borne in mind in interpreting the facts herewith presented regarding the 
economic groups served. 

During 1922, of the total days of treatment furnished by all ten hos- 
pitals, 54 per cent were paid for in full, 12 per cent were partly paid for, 
and 34 per cent were free. These facts for the individual hospitals are 
shown in the following table and in Chart C, page 49. 



48 



Hospital and Heai/th Survey 



Full Pay, Part Pay and Free Care, by Hospital— 1922 

No. No. No. 

Total Full Per Part Per Free Per 

Days Pay Cent Pay Cent Days Cent 
of Care Days Days 

Public Institutions — 

San Francisco 158,027 158,027 100 

University of California.... 61,049 21,127 34 19,961 33 19,961 133 

: Totals 219,076 21,127 10 19,961 9 177,988 81 

Privately Controlled Institutions — 

Children's 60,128 33,977 65 7,780 13 13,391 22 

Franklin 54,813 52,343 95 2,470 5 

French 46,663 46,560 99 ...... . . 103 1 

Lane and Stanford University 79,138 43,299 55 33,949 43 1,890 2 

Mary's Help 34,379 29,946 87 1,975 6 2,458 7 

Mount Zion 44,147 25,152 57 8,250 19 10,745 24 

St. Luke's 39,457 37,029 94 864 2 1,564 4 

St. Mary's 51,766 43,934 85 4,759 9 3,973 6 

Totals 410,491 317,220 77 57,577 14 35,694 9 

Grand Totals .' 629,567 338,347 54 77,538 12 213,682 34 

Of the two public institutions, the San Francisco Hospital furnishes 
free care to all patients, with the exception of a few paying patients 
admitted to the communicable disease department. The University of Cali- 
fornia Hospital does not assemble facts which would indicate the service 
which was free to patients, but estimated that one-half of the total days of 
care, other than full pay, were furnished without cost and the remaining 
half were paid for in part, the cost of maintenance of patients paying noth- 
ing, or in part, for their hospital care, being met by State funds. 

Of the eight privately controlled institutions, Mount Zion Hospital and 
the Children's Hospital gave over 20 per cent of free service, the remain- 
ing institutions, Mary's Help, Franklin, French, and Lane and Stanford 
University Hospitals furnishing 6 per cent or less of their services free. 

The information furnished by the Franklin Hospital, showing 79 per 
cent of full pay and 17 per cent of part pay service, was not used as the 
9149 part pay days which were given during the year were furnished to 
members of the German General Benevolent Society, and for this the hos- 
pital received $56,870.95 from the Society. These 9149 days, therefore, 
are included with the institution's full pay days. 

Likewise, the information furnished by the French Hospital, showing 
28 per cent full pay, 23 per cent part pay, and 49 per cent free service, 
was not used. The official report of the French Mutual Benevolent Society 
indicates that the total hospital service, with tfte exception of 103 free days 
of care, was furnished to full-pay private patients or members of the 
Society. The 10,696 part pay days and 23,202 of the 23,305 free days, 
therefore, were fully paid for and are thus classified by the Survey. 

The combined data regarding the economic groups cared for, point to 




(J 

H 
< 
O 



50 Hospital and Health Survey 



the conclusion that, with 77 per cent of the service given to full-pay 
patients, the facilities of the privately controlled hospitals are devoted 
mainly to this patient group; that, with the exception of the generous free 
service furnished at the Children's and Mount Zion Hospitals, only a small 
amount of service is given without cost to patients — but 9 per cent; and 
that the service to patients paying in part for their care is relatively small — 
14 per cent. 

These conclusions are borne out by the analysis of the rates being 
paid by the patients in nine* of the hospitals on June 21, shown in the 
following table : 

Rate of Payment of Patients in Hospitals — June 21, 1922 

Totals Full Per Part Per Free Per 
(100%) Pay Cent Pay Cent Cent 

Public Institutions — 

San Francisco 428 ... • 428 100 

University of California 149 56 38 40 26 53 36 

Totals 577 56 10 40 7 481 83 

Privately Controlled Institutions — 

Children's 194 120 62 36 19 38 19 

Franklin 141 101 72 38 27 2 1 

Lane and Stanford University 252 230 91 9 4 13 5 

Mary's Help 123 97 79 15 12 11 9 

Mount Zion 118 70 59 23 20 25 21 

St. Luke's 119 115 97 .. .. 4 3 

St. Mary's 151 130 86 12 8 9 6 

Totals 1098 863 78 133 11 102 9 

Grand Totals 1675 919 55 173 10 583 35 

One of the important developments in the hospital world is the grow- 
ing demand by self-supporting families of moderate means for hospital 
care. 

This is shown by the demand for beds in small wards accommodating 
from two to six persons, a demand which has increased markedly through- 
out the country during the past few years. 

In hospital operation, analyses of the volume of service rendered to 
the various economic groups and the type of facilities demanded, are 
increasingly used by hospital boards and administrators as a basis for 
determining the character of the provision which must be made to meet 
community requirements. For example, a hospital board presented with 
facts showing that certain large private rooms are used to but 50' per cent 
of their capacity while wards and semi-private wards show 80 per cent of 
use would be inclined to convert a portion of the rooms to semi-private 
uses. Again, analyses of the percentage of use of the rooms of different 

*The information furnished in this particular by the French Hospital was not 
used, as it indicated that 37 per cent of the patients were free, nine having been' in 
the hospital over a year. As only 103 free days of care were furnished during the last 
year, it was suspected that the information sought was not understood. 



Services for the Sick 



51 



prices might indicate a low use of high-priced rooms and a high use of 
moderately priced rooms. Presented with such facts, a board would nat- 
urally request data covering a definite period regarding the number of 
part-pay patients applying who could not be accommodated, in order to 
have an accurate basis for action. 

With the exception of Lane and Stanford University, none of the hos- 
pitals furnished information which indicates that such analyses are made 
and no studies have been made which would show the extent of the demand 
for part-pay facilities either individually or collectively. There is, how- 
ever, a general sentiment among hospital administrators that increased pro- 
visions for part-pay patients are urgently needed. 

It must be apparent that the breadth of the hospital service which 
these ten institutions make available for the community is reflected in part, 
in the nature of the provisions for the different economic groups, as they 
determine to a great extent the portion of the sick of the community which 
the hospitals serve. 

The free hospital beds of the city are the 896 beds at the San Fran- 
cisco Hospital and the endowed beds at the privately controlled hospitals, 

as follows : ^ < 

.bree and 

Endowed Beds 

San Francisco 896 

Children's 28 

St. Luke's 5 

French 5 

St. Mary's . 6 

Franklin 4 

Lane and Stanford None 

University of California None 

Mount Zion 50 

Mary's Help 2 

996 

Comparison of the available free days of care represented in the free 
beds at the privately controlled hospitals and the free service given during 
1922, indicates that most of the hospitals provide free service exclusive of 
that free service to part-pay patients, far in excess of the amount which 
could be given if the designated free beds alone were used for this pur- 
pose. The chief exception to this fact was Mount Zion Hospital, at which 
the part-pay service constituted 19 per cent of the service for the year, a 
percentage of part-pay days of care only exceeded by the two university 

hospitals. Number of Days' Number of Entirely 

Care Available in Free Days of Care 
Endowed Beds Furnished During 

1922 

Children's 10,220 12,390 

Franklin 1,460 2,202 

French No data 103 

Lane and Stanford None 1 ,890 

Mary's Help 730 2,458 

Mount Zion 18,250 10,745 

St. Luke's 2,920 1,564 

St. Marv's 2,190 3,073 



52 Hospital and Heal/th Survey 



It is clear, however, that neither the free service at these hospitals and 
the San Francisco Hospital, nor the part-pay facilities generally meet cur- 
rent needs, as the information furnished the Survey indicates that the diffi- 
culty experienced by physicians and organized social groups in hospitalizing 
free patients and those paying moderate rates, is no minor matter. *The 
opinions of the members of the San Francisco County Medical Society on 
this subject are highly important, and reflect conditions that certainly 
deserve special consideration. Individual replies from physicians stated: 



<c 



a- 



'There is a serious need for a hospital for patients who are not charity cases, 
but who cannot pay from $6 to $7 a day and up in our private hospitals." 

"It has been my experience that the very poor people of this city are better 
taken care of than any other class. The need is for some system whereby the 
man earning a salary of from $150 to $200 per month can get medical care with- 
out going to a free clinic, and thus being pauperized." 

"More beds are needed for the man who can pay $10 a week. It costs too 
much to be sick. There is nothing new in this statement, and though I have 
given it much thought, I can see no way to lower the cost with fairness to all." 

"There is undoubtedly a need for more beds at more moderate rates for 
wage-earners. I find great difficulty in hospitalizing medical patients, due to the 
great expense of hospital beds." 

"Hospital beds are needed for free and part-pay patients. There is everlast- 
ing red tape to be cut before I can get real assistance for medical patients." 

'There are too many boarders in hospitals and too few free beds." 

'I firmly believe that the services dealing with the preservation of disease 
and the treatment of the indigent are exceedingly well covered. The time must 
come, however, when those in moderate circumstances should be placed in a 
position where they can buy and pay for medical attention. Private or special 
nursing still needs adjustment." 

The following are the more important and commonly held opinions 
expressed by the social agencies : 

"As far as my knowledge goes, we have the best hospital care that I have 
known in the entire United States. I do feel this: that the San Francisco Hos- 
pital should have a ward or wards where people could pay a fair sum of money 
for medical care — $30 or $35 per month, instead of the high and almost pro- 
hibitive prices of hospitals for the working class, or the medium class of people, 
financially. It is almost impossible for the average wage-earner to pay the prices 
charged where they are required to go to wards or to special rooms in the 
various hospitals. Some law should be enacted giving the city and county the 
right to proceed criminally or civilly, or both, against relatives who are in a 
position to pay." 

"There is undoubtedly need for more free service at both the University hos- 
pitals. It is difficult to get the best work from the pl^sicians who are giving 
volunteer service in the clinics if they cannot keep their patients in their own 
hospitals when such care is needed. If the patient is placed in the same hos- 
pital, the clinician can keep in close touch with his patient through the courtesy 
of the staff physicians, even when he must transfer the actual medical care to 
another physician." 

"There is a crying need for a department for part-pay patients. The problem 
presents itself time and again as patients have to be sent home from hospitals 
too soon after severe operations and illnesses because they cannot afford to sta} r 
as long as needed." 

"It is practically impossible for the unskilled and the semi-skilled, and even 



Services for the Sick 53 

the skilled, to meet the cost of a long illness if they are unwilling to avail them- 
selves of the free clinics or to ask for free care at the San Francisco Hospital, 
or if they are not in a somewhat personal relationship to a family physician who 
will make special rates for them. For this reason, it is certain that there is a 
great need for greater hospital facilities at rates far lower than those now 
charged for ward beds. 

"At the San' Francisco Hospital there are still empty wards available. If 
these wards are not to be needed in the near future for patients who cannot 
pay at all, would it be advisable to establish in the San Francisco Hospital the 
policy of taking patients who could pay small amounts. If the policy is^ the 
right one, the legal difficulty can easily be overcome by getting the Supervisors 
at regular intervals to reappropriate to the hospital the money that has been 
paid in to the city's general fund. The establishment of this system would prob- 
ably net a substantial income to the city, which might be used to supply the 
additional nursing service so much needed. Probably many patients are accepted 
today as free patients who could afford to pay a reasonable amount, but could 
not pay the amount charged in the existing hospitals for ward service. The 
establishment of such a policy might be a mistake if the need for free beds was 
in the near future apt to grow to the extent of demanding all the space in the 
City Hospital. This question of policy must, of course, be determined by the 
hospital expert." 

The physicians' reactions to inquiry as to the adequacy of hospital 
facilities indicate dissatisfaction with the delays and obstacles connected 
with the admission of patients to the San Francisco Hospital. To quote : 

"There is unnecessary delay in admitting patients to the Detention Hospital. 
At times this is also true regarding admission to the San Francisco Hospital of 
serious cases demanding early attention, and of the Isolation Hospital. " 

"I have had difficulty in obtaining bed care at the San Francisco Hospital 
for destitute surgical cases." 

"It is difficult to get hospital care for medical cases. The City and County 
Hospital is seldom available at short notice for medical cases. I have not infre- 
quently been informed by patients who are able to pay for care, that they have 
succeeded in getting free care, both at the San Francisco Hospital and at clinics. 
On the other hand, I have known needy patients to be kept waiting for an 
opportunity to enter the San Francisco Hospital." 

"It has been my experience that it requires all kinds of references to get 
a patient in the San Francisco Hospital. " 

"The City and County is very good when they have the room. If they 
could transfer some of the 'old chronics' to some other place to make room 
for the acute sick it would be a help. Sometimes we have been obliged to wait 
three or four days to get a 'worthy' patient into this hospital." 

The demand for free hospital beds is greatest during the winter 
months, partly due to the climatic conditions and partly due to the fact that 
men from the farms, fisheries and lumber camps come to the city during 
the winter. The need of hospitalization of these and other groups of non- 
resident sick who cannot pay for care and yet are not legitimate charges 
upon the city, creates a situation which, in the opinion of members of the 
medical profession and social workers, demands attention. To quote some 
of the opinions expressed : 

"The patient we have the most difficulty taking care of is the man without 
funds who comes in from out of town. He is not eligible to a bed at the San 
Francisco Hospital, and often needs hospital care or possibly operation. Our 
social service workers work hard and do all that can be done, but there are not 



54 Hospital and Heai/th Survey 



enough Funds available to provide for many of these fellows who are in need of 
the care." 

"More Free bods are needed, especially for non-residents of the city and of 
the State. The transient population offers a large problem in California — the 
financial aspect is not the least important. May I suggest that the charities of 
the country establish a service similar to the clearing-house of the banks? 
Through such an institution the transient sick poor could be treated, in the city 
of their new residence and be supported by the charities of their home cities." 

'The chief difficulty I have encountered has been the cases of indigent sick 
who have not been in San Francisco for the required length of time to qualify 
for the San Francisco Hospital. If a man drops in the street the Central Emer- 
gency Service must look after him, but as long as he can drag himself around 
there is no place for him." 

'More free beds are needed for patients not eligible to the San Francisco 
Hospital. I have difficulty in regard to the patient from outside the county who 
has no funds and who needs surgical treatment not available in his own county." 

It must be obvious that, collectively, these opinions indicate that there 
are unsolved problems of importance to the city's sick and to the progress 
of medical care and medical education in San Francisco. The community 
is fortunate in having within its midst such a wealth of interest and indi- 
vidual appreciation of the desirable elements of community health service, 
for they constitute a nucleus for fair and unhurried study of the subjects 
here presented. 

(c) MEDICAL SERVICES MAINTAINED 

All of the ten hospitals receive patients with general medical and sur- 
gical conditions, and maternity patients. But two of the institutions, the 
San Francisco and Children's Hospitals, receive patients suffering from 
acute communicable diseases. One, the Lane and Stanford University 
Hospital, receives patients with mental and neurological conditions. None 
of the hosptials, with the exception of the San Francisco Hospital, receive 
patients with venereal diseases or with active pulmonary tuberculosis. 

The chief fact indicated by the foregoing limitations of service are 
the restrictive policies regarding neurological conditions, tuberculosis, and 
venereal diseases in the private hospitals, discussed in Section II. 

As mentioned earlier in this section, the ten hospitals, as a group, pro- 
vide all the accommodations in the city for acute communicable diseases 
and tuberculosis, and 94 per cent of the beds definitely set aside for the 
care of particular conditions. 

Exclusive of the 250 beds for tuberculosis at the San Francisco Hos- 
pital and the 146 beds for acute communicable diseases at the San Fran- 
cisco and Children's Hospitals, the beds assigned to the various medical 
services in the ten hospitals are as follows : 



Services for the Sick 55 



Beds Assigned to Various Medical Services 

Medicine — Beds 

General Medicine ' 320 

Pediatrics (including 114 for new-born) 249 

Skin 2 

Neurology . 1° 

Venereal 75 

Surgery — 

General Surgery 304 

Gynecology 43 

Genito-Urinary ° 

Orthopedics 48 

Eye 2 

Ear, Nose and Throat 2 

Obstetrics 148 

Used Interchangeably 113o 

Total 2386 

Grouped according to the four main services, as below, the number of 
beds for medicine exceeds that for surgery, although this is not the case 
if the 75 beds for venereal diseases at the San Francisco Hospital are 
excluded from the first-named group: 

Medicine . 433 

Surgery 405 

Obstetrics 184 

Pediatric 249 

Used Interchangeably 1135 



2386 



It is generally felt that there should be as many beds available for 
medicine and the medical specialties as for surgery and the surgical spe- 
cialties, but the facts collected do not indicate that this is the case in this 
group of hospitals. The high proportion of the beds provided for surgery 
is further emphasized by the fact that a large percentage of the beds not 
definitely assigned and used interchangeably in the ten hospitals, and a 
still larger percentage of the beds in the nine hospitals of the city not 
included in this Survey are, as a matter of experience, used for surgical 
conditions. 



56 



Hospital and Health Survey 



The facts collected on June 21 indicate the ratio of the medical, sur- 
gical and obstetrical patients in the individual hospitals on one day: 



Percentage of Medical, Surgical and Obstetrical Patients in Hospitals 

June 21, 1923 

Medical Surgical 

Per cent Per cent 
Public Institutions — 

San Francisco (including Contagion) 52 42 

University of California 36 50 



Total 48 

Privately Controlled Institutions — 

Children's 

Franklin 

French 

Lane and Stanford University 37 

Mary's Help 32 

Mount Zion 

St. Luke's 

St. Mary's 31 



43 



Obstetrical 
Per cent 

6 
14 

8 



34 


54 


12 


33 


61 


6 


38 


53 


9 


37 


56 


7 


32 


57 


11 


33 


55 


9 


26 


65 


10 


31 


51 


9 



Total 



Grand Total 



33 
37 



56 

52 



A further analysis of the census day data, showing the number of 
patients under the supervision of the various medical services at the dif- 
ferent hospitals, is given in the following table: 

Public 
— Institutions — Privately Controlled Institutions 



m 
p 

3 


C ■ 

3 < 

i— ■ • * 


-3 * 

D 

-t- 


-- • 


•1 

P 




3 


P 


O 


C/5 


•-t 

p 
3 

o 

o 


< i 
O 


2. ■ 


—— * 


3 

s 

31 


3 
n 

3* 




3 
3 


3 


o 




3^ 

Si" 


3 




Help 
id Sta 


N 

S" 

3 




o 


o 
■1 

3 
i— > • 

P 










3 

O 
H 

a* 









m 



p 

CD 



O 

P 



o 

rt- 

(73 



General Medical. .. 133 
General Surgical. . . 146 

Obstetrical 24 

Pediatric 

Orthopedic 11 

Neurological 8 

Ear, Nose and 

Throat 1 

Eye 

Genito-Urinary ... 3 
Gynecological .... 17 

Venereal 13 

Drug 5 

Communicable .... 64 

Dental 

Not stated 3 



33 
67 

22 
20 



166 

213 

46 

20 

11 

8 

1 

*3 

24 

13 

5 

64 



36 
62 
21 
19 
44 
1 



47 

86 

8 



49 
43 
12 



11 



11 

• • 

9 

6 



67 
111 
19 
12 
5 
14 

8 

1 

3 

10 



39 

70 
114 



31 

57 

15 

3 



4 
5 
2 

1 



31 

77 
11 



47 

77 
14 



13 



347 

583 

114 

34 

49 

15 

23 
6 

14 
17 



11 

1 

14 



513 

796 

160 

54 

60 

23 

24 
6 
17 
41 
13 
5 

75 

1 

17 



Totals 428 149 177 194 141 130 252 123 118 119 151 1228 1805 



Services for the Sick 57 



Although the foregoing facts present the experience of but one day 
and, therefore, cannot be taken as conclusive, they indicate to some degree 
the type of medical conditions hospitalized in the several institutions. At 
some of the hospitals the patients under the supervision of the subsidiary 
medical and surgical services were not so classified as to permit such 
an analysis. At four of the hospitals, the Franklin, St. Mary's, Mary's 
Help, and St. Luke's Hospitals, the patients were classified only under the 
three main patient groups — medical, surgical, and obstetrical. At the Uni- 
versity of California Hospital, in addition to the foregoing classifications, 
pediatric and gynecological patients were separately indicated. At the 
French Hospital, eye, ear, nose and throat, genito-urinary and gynecologi- 
cal classifications were used. At the Children's Hospital, in addition to the 
medical, surgical, and obstetrical, pediatric and communicable diseases 
classifications, orthopedic and neurological patients were separately grouped. 
At San Francisco, Lane and Stanford University, and Mount Zion Hospi- 
tals the classifications, according to major subdivisions of medical service, 
were more precise and numerous than in the other hospitals. 

The experience of San Francisco with the hospital isolation of the 
common communicable diseases of childhood is interesting because of 
its general similarity to that of other cities of the country of 500,000 
population and over: 

( San Francisco, June, 1922-May, 1923 . Percent 

Patients ^Vff i tl! z ^ d 



Cases Re- Hospitalized United States 

ported to San Francisco Per cent nf c nn mn r> nn 

Health Deaths and Children's Hospital- IS ftP ?„ P ." r 

Department Reported Hospitals ized 1920 

Diphtheria 1265 108 429 33.9 24.3 ' 

Scarlet Fever .... 630 8 171 27.1 25.3 

Measles 781 8 61 7.8 3.1 

Whooping Cough. 568 28 44 7.7 2.1 

Apparently San Francisco hospitalized a higher percentage of patients 
with these diseases than is the case generally in other large cities, but the 
difference in the practice of communities in reporting diseases must be 
taken into account before accepting this table as showing an entirely cor- 
rect comparison between the per cent hospitalized in San Francisco and 
that in other cities. 

The number of days' care furnished to the various patient groups — 
the true basis for determining the relative amount of hospital service 
devoted to the various medical services — is not known, due to the fact that 
but three of the hospitals, the Children's, Franklin, and University of Cali- 
fornia Hospitals, assemble these important data. The percentage of ser- 
vices furnished at these three hospitals during 1922, grouped according to 
medical service were : 

Medical Pediatric Surgical Obstetrical 
Per cent Per cent Per cent Per cent 

Children's 6 67 14 12 

Franklin 21 . . 72 8 

University of California 25 14 42 14 



58 Hospital and Health Survey 



It is unusual to find a group of hospitals accumulating and assem- 
bling so little information for their own use or for the public, regarding 
the character and amount of service which is furnished the various patient 
groups. The methods of assembling and analyzing facts used in the lead- 
ing hospitals of the country have not yet been adopted. Thus, many- hos- 
pital executives review monthly the percentage of use of the beds assigned 
to the different services, for the information of their boards and attend- 
ing staffs. For example, a hospital with the beds assigned to neurology 
showing a high degree of use and with those assigned to dermatology, 
gastroenterology, etc., showing low percentages of use, has problems 
related to service for the sick and to intern and nursing education which 
can be intelligently acted upon. Is the low use of certain beds due to 
too liberal assignments to these specialties or to the conduct of these ser- 
vices, in either the hospital or the dispensary? What are the causes for 
increased demand for beds in one service and decreased demand for 
another service? For what percentages of these special groups is bed 
care needed to meet the sickness demand of the community? What must 
the range of cases include to furnish interns and student nurses with a 
comprehensive experience in the particular disease groups? 

With the exception of the data furnished by the Children's Hospital, 
no facts were available which permit of even brief analysis of the various 
medical groups served. As the data collected by this one hospital are not 
analyzed with reference to the extent to which its facilities are used or to 
the sickness needs of the community, their chief value is lost. 

The combined medical opinion on the subject of hospital accommoda- 
tion suggests a general need for increased beds for general medical condi- 
tions, with special emphasis upon the needs of mental and neurological 
patients, the inadequacy of the accommodations for children and for 
patients suffering from eye conditions and venereal diseases. To quote: 

''There is no way of keeping under observation or treatment acute and bor- 
der-line mental patients. No systematic psychiatric work is being done that I 
know of." 

"Service for mental cases, and especially acute delirious cases, is extremely 
poor. No hospital will keep them. They receive wholly inadquate care at the 
Detention Hospital and are sent to Napa. Private hospital facilities for psychi- 
atric patients should be available at the San Francisco Hospital." 

"I have great difficulty in obtaining free beds for nervous and mental 
patients. There are beds available at $3 a day to take care of the patients who 
can pay this fee, but funds for free beds are very limited. More beds are needed 
at the San Francisco Hospital for free mental patients." 

"I would call your attention to the utter lack of any provision for patients 
with the milder forms of mental diseases. There is no space where a clinic 
patient can be placed for observation and care. He must be left an out-patient 
or be committed to the State Hospital. There is also a great need of a similar 
place for patients of moderate means. The minimum rate of privately owned 
institutions is $35 a week/' 

'There are no adequate means of caring for private or clinic patients with 
mental disturbances. A psychiatric hospital — a ward at San Francisco Hospital 
or at the University of California Hospital would be an immeasurable boon to 



Services for the Sick 



59 



the community — there being absolutely no means in the city adequate to the 
needs of mental cases." 

"I can find no place in San Francisco for free or part-pay care of open 
tuberculosis in young children." 

"In the question of treating an individual with tuberculosis as matters now 
stand only the advanced cases can get hospital care, and naturally prognosis is 
poor. The early case is the one on which attention should be focused and bed 
care provided in a hospital if good results are to be obtained instead of treating 
them as now treated — ambulatory cases at out-patient departments." 

"There is a great need of an extra-urban tuberculosis hospital." 

"The chief necessities in tuberculosis work are — a sanitarium for ambulatory 
and semi-ambulatory groups, and increased nursing and trained professional 
supervisory staffs." 

"I have difficulty in hospitalizing pulmonary tuberculosis cases that are unable 
to pay for sanatorium treatment." 

"There is a crying need for taking care of malignancy along modern lines. 
I have great difficulty in handling patients with malignant diseases who need, 
but cannot afford to pay for the cost of Roentgen therapy." 

"San Francisco has poor provisions for contagious cases. I find there is 
little done systematically for heart cases." 

"The facilities for venereal patients are inadequate. The San Francisco Hos- 
pital will take such patients, but the other hospitals will only take such cases in 
private rooms, which usually means that, as a rule, a patient is not hospitalized 
as he cannot pay the price. As a result, they are a menace in the home or in 
public places, such as hotels, rooming-houses, etc." 

The foregoing opinions and similar data presented earlier in this 
report, point to the difficulties experienced in obtaining hospital care for 
patients with limited means, suffering from particular illnesses. 

An analysis was made of the information* collected on the census day, 
relative to the number of medical, surgical, and obstetrical patients which 
were full pay, part pay or free, with the following result : 

Full Pay Part Pay Free Total 
Per Per Per Per 

cent cent cent cent 

Medical 44 9 47 100 

Surgical 61 11 28 100 

Obstetrical 69 9 22 100 

(Not stated) 82 .. 18 100 

These percentages indicate that on the day in question approximately 
one-half of the medical patients were free, something less than one-half 
paid fully for their care, 9 per cent being part pay. Of the surgical 
patients only 60 per cent were full pay, less than 30 per cent free, and 11 
per cent part pay. Of the obstetrical patients practically 70 per cent were 
full pay, a little over 20 per cent free, and 9 per cent part pay. The strik- 
ing facts are the small extent to which the part-pay patients in any of the 
three groups were hospitalized, the high percentage of full pay surgical 
and obstetrical patients, and the large percentage of free medical patients. 

As similar analyses for the hospitals as a group could not be made, 

♦Exclusive of the patients at the French Hospital. 



60 Hospital and Health Survey 



due to the lack of the facts for such a study, it is not known whether this 
experience on the census day represents the usual conditions. To be of 
value and to serve as a basis for so important a matter as rate-setting and 
redistribution of beds to medical services, comparable data, covering a 
number of months should be assembled by each hospital. 

Inadequacies of Hospital and Medical Services 

There are certain aspects of the services for the sick which received 
attention from the medical profession in replies to inquiry from the 
Survey, and certain inadequacies of hospital and medical care revealed 
through study, which should be considered. 

Specific conditions mentioned by physicians relate to various phases 
of the care of the sick of the community and, although not included in 
the matters receiving the attention of "the Survey, are highly important. 
The following opinions call attention to conditions which relate to or 
hamper hospital medical service: 

It is difficult to hospitalize pneumonia patients. 

Night clinics are needed for women who work. 

Reports to physicians from hospitals are unknown. 

Provision for after care of drug addicts is inadequate. 

Provisions available for the handicapped are inadequate. 

Wet nurses are needed at all hospitals. 

Dental work is limited to emergency treatments. 

Facilities for the rehabilitation of cripples are needed. 

There are too many boarders in hospitals. 

Auxiliary diagnostic facilities are costly. 

There is too little control of laboratories. 

Laboratory fees are too high. 

Salvarsan at cost can only be obtained with difficulty. 

There are insufficient X-ray films at the City Hospital. 

After Care 

The after care of hospital patients is a responsibility of the medical 
staff and the determination of a program for after care is a medical 
matter which cannot properly be delegated to others. 

The need for after care as reflected in the character and extent of 
instruction to patients prior to discharge and the provisions made for 
return -to complete health, is one that is only partially met in the ten hospi- 
tals. Case after case visited during the course of the convalescent study 
of the Survey indicated this defect of medical care. 

Although the majority of the hospitals maintain contact with certain 
types of cases following discharge — some of them providing nurse follow- 
up of special patient groups — after care is provided for relatively few 
patients. 

In a large percentage of the 160 patients visited in their homes, con- 
tact with the medical staffs responsible for their care had ceased on dis- 



Services for the Sick 



61 



charge, and no provision had been made for other subsequent medical or 
nursing supervision. This fact is illustrated by the following cases : 

Case No. 1 — A patient who had been operated upon in one of the hospitals, 
where she remained for four weeks, had a fecal fistula on discharge. Following 
her return home she had a severe hemorrhage, but as the hospital had no bed 
available, she went to another, where she remained five days, and was discharged 
unimproved with a diagnosis of carcinoma of the cervix and recto-vaginal fistula. 
When visited she was sick in bed, had no means of obtaining the nursing care 
demanded by her condition, and was in need of immediate hospital care. The 
hospital in which the patient had been for so long under treatment was using 
less than 60 per cent of its available beds at this time. 

Case No. 2 — A case in which continued medical supervision was needed was 
that of a patient who, when she came to San Francisco, was under treatment at 
one of the dispensaries for syphilis, but as the salvarsan made her sick, she 
only took a few treatments. About a year later, when pregnant, she went to 
another hospital for prenatal care, having regular urine examinations but no 
blood examination. Her baby lived four months, was always sick and was taken 
care of as a free patient in a third hospital. The patient, when visited, was 
recovering from an operation for appendicitis and was referred back to the first 
dispensary by the visitor for the Survey for examination and treatment of her 
syphilitic condition. 

Case No. 3 — This patient, a child of two years, who had been removed from the 
hospital against the advice of the staff physician, but whose condition was suffi- 
ciently serious to require special attention even under the foregoing circum- 
stances, had fallen from a second story window to the sidewalk, probably strik- 
ing his head, as blood ran from his nose and ears and as he was unconscious 
for seven days. On leaving the hospital, one ear was discharging pus, and the 
mother was told by the doctor that the child should continue under medical 
supervision and to take him to a public dispensary, distant from her home. 
Although she stated she was keeping a boarding-house and could not go so far, 
she was not told that she lived only a few blocks from another dispensary. 

When visited, the child's ear was still discharging pus. As the doctor at 
the hospital told the mother to irrigate the ear, but had not told her what to 
use, she had been irrigating the ear with lysol solution as strong as the child 
could stand. 

Not only was this patient in need of home nursing care and dispensary care, 
but, due to the poor instructions the mother received, he was having treatments 
which were seriously unsuitable, if not dangerous. 

Case No. 4 — This case, indicating a need for persistent follow-up, was a child 
of five with club feet, who had been a free patient in the hospital for a month. 
When much younger he had been under treatment and wore a cast, but because 
of the expense his parents had neglected to keep up with the treatments, so the 
work had to be done all over again. While in the hospital, the child had had an 
operation and a cast applied on one leg, and was shortly to return to have 
similar treatment for the other leg. The home was exceedingly dirty, the mother 
ignorant, and the instructions given her had not been understood. It should 
have been obvious, in dealing with the case the second time, that favorable end- 
results depended on special supervision and instructions, but there was no indi- 
cation that the seriousness of the situation had been made clear to the parents. 

We have only to contrast the foregoing and other cases cited later 
in this section, with the following instance of excellent follow-up and 
after care, to point out the results which are possible when there is a 
program for further care, and when sufficient workers for follow-up are 
available: 

Case No. 5 — The patient, a three-year-old child with one leg shorter than 



62 Hospital and Health Survey 



the other due to congenital syphilis, had been in the hospital for only a short 
period for observation and treatment, but had been for many months under the 
supervision of the out-patient department. The parents had been fully instructed 
at the clinic regarding the child's condition, treatments, etc., and follow-up visits 
had been made to the home by the hospital's social service department, so ,that 
every precaution was being taken to secure favorable results. The parents knew 
the character of the treatments, that they would have to be continued for many 
months, and that everything was being done that the hospital could do. 

This case is illustrative of the many cases visited in which the follow- 
up was effective and in which careful instruction had been given by the 
physician or surgeon responsible for the case. 

The picture presented by those patients who sought the instruction 
and medical direction which should have been provided as part of their 
medical care without effort on their part, is a serious one: 

Case No. 6 — A little boy of eight, who had been in the hospital over two 
months with a fractured femur, was discharged to his mother with insufficient 
instruction. As his right leg was in a cast from the hip to the ankle, she asked 
the nurse in charge of the ward how to care for him. The nurse declined to give 
any advice and referred her to the doctor. The mother had to hunt him up 
herself and found him in a room doing a dressing. The only instructions he 
gave her were to take the child to a public dispensary. The boy was kept in 
bed for a week after returning home and was then allowed to use his leg. After 
ten days the mother telephoned the same doctor at the hospital and asked him 
when she should take the boy to the clinic and what she should tell them there. 
When it was understood that the boy had been permitted to walk, the mother 
was told to keep him off his feet for a week and then to bring him back to the 
hospital, because the doctor was afraid the bone might not have united com- 
pletely, as it had been used too soon. 

Case No. 7 — Another case, a little girl of six in the hospital two days fol- 
lowing a tonsillectomy, was brought home in an ambulance. The mother had 
received no instructions regarding the after care of the child, so, as the patient 
was suffering, she took her back to the hospital, four days after discharge, to 
find out what should be done. 

Case No. 8 — A woman who had been in the hospital for two weeks with 
neuralgia, arteriosclerosis and hypertension was given no instructions on dis- 
charge, nor referred to any dispensary for follow-up. As the patient felt ill and 
weak after leaving the hospital, she went back to see the doctor who had cared 
for her, but she was unable to talk with him because he was busy. She then 
went to the ward and asked the mirse in charge if she could make arrangements 
to see the doctor. The nurse was new and did not know the patient, so she 
was apparently not much interested and said the doctor might come in any 
minute or he might not come in at all. 

The needs of a large number of patients would have been met by 
reference to a dispensary where they could have obtained the needed medi- 
cal supervision. To cite a few of those showing the more serious needs: 

Case No. 9 — A man of 50, in the hospital almost two months because of a 
fractured leg, was given no instruction on discharge from the hospital, or the 
name of any dispensary where he might go for medical supervision or needed 
physiotherapy. His leg was still very stiff from the cast and the patient was 
worried about his slow improvement. He was in need of advice as to where 
he could obtain the needed medical care, special treatment, and medical opinion 
regarding the condition of his leg. 

Case No. 10 — A little girl of five, in the hospital for sixteen days with ton- 
sillitis, was discharged to her mother without instructions as to her further care. 



Services for the Sick 



63 



The mother did not speak English and may have misunderstood directions, but 
she knew of no place to go for free instruction for the feeding and care of either 
this child or of her ten months' old baby. A physician had made all arrange- 
ments for her at the hospital where she paid $2.50 a day, but she could not 
afford the expense of a private physician for further medical care. 

Case No. 11 — A homeless man of 36, in the hospital for almost two months 
with acute arthritis, when discharged went to a rooming-house. He was without 
money and was being suported by friends who felt sorry for him, giving him 
25 cents a day for his meals. Some days he had one meal and some days 
three meals. All his teeth were removed at the hospital, but as he had no 
money to get new teeth, and as he was not referred to any dispensary for dental 
or other care, his condition was unknown to the agencies which might have 
assisted him. He felt his condition was almost as bad as when he first went to 
the hospital. The patient was referred by the worker for the Survey to the 
social service department of the dispensary to which he should have been 
referred, and he was immediately provided with the needed medical and dental 
care. 

There is no one patient group probably for which the need for instruc- 
tion has been so emphasized as the maternity patient. While the follow-up 
for such cases is excellently provided for by some of the hospitals, in 
others there is no plan for further care, as illustrated by the three follow- 
ing cases, all patients at the same hospital : 

Case No. 12 — The patient, a private patient, was a young Portuguese mother 
of 19 who had had her first baby. She was the type who would attend and 
would be much benefited by a well-baby conference such as is conducted at 
the Emporium. The mother and baby were in good condition, but the mother 
was entirely ignorant about feeding and baby care. 

Case No. 13 — This mother was in need of medical care and had just called 
her private physician who had delivered her at the hospital. The baby was well, 
although it was the mother's practice to nurse it whenever it cried. Its feet and 
legs were tightly wrapped, preventing any movement, and the surroundings were 
unhygienic, entirely lacking needed ventilation. This mother also is the type of 
patient who would attend a well-baby conference, but had not been recom- 
mended to the one in her neighborhood. 

Case No. 14 — This mother feeds her twins at irregular intervals and needs 
instruction in the general care of babies, also in the preparation of supplementary 
feeding. She was not referred to any well-baby conference and only consults 
her private physician in case of sickness. 

The time to arrange for a patient's after-care is prior to discharge. 
It is natural to suppose that medical care includes inquiry regarding home 
conditions, instructions as to physical condition, and directions as to the 
course to be followed after leaving the hospital and, in those cases in which 
social service investigation reveals social or economic problems, reference 
to the social service department so that adjustments will be made which 
will insure the patient the particular institutional care needed. The follow- 
ing indicate that such medical supervision is not always provided : 

Case No. 15 — A little boy of three was discharged after six days in the hos- 
pital with a diagnosis not definitely determined but judged to be sub-acute tuber- 
culous peritonitis. The mother was told to take him to the hospital's dispensary 
and was given detailed instructions about his care. The hospital's nurse had 
called and advised preventorium care, because, although the mother is intelligent 
and the child is receiving good care at home, as there are two other children 
under four, she had insufficient time to carry out the instructions. It was quite 
apparent that the mother's entire time was being taken up in care of the sick 



64 Hospital and Health Survey 



child, to the detriment of the other children and to her own health. The ques- 
tion of preventorium treatment had not been taken up with the mother by either 
the doctor or intern, and although evidently recommended by the physician in 
charge of the case, its importance had not been brought home to the parents. 

Case No. 16 — Convalescent institutional care was indicated for a man of 38 
who had been for a month in the hospital with chronic nephritis. He had had 
many previous attacks and had been ill and unable to work for over three 
months. He felt he had been much improved by his hospital stay, the pufriness 
had gone from his hands and feet, but he was still weak, thin and anemic. Pre- 
viously he had done janitor work, and a physician at the hospital had told him 
he might be able to run an elevator. His physical condition indicated that he 
was not able to work, when visited shortly after discharge. His wife is lame 
and able to earn a little money by sewing at home. One of the relief agencies 
has given aid on different occasions, and at the time it was giving a quart of 
milk a week. It was the opinion of the visitor for the Survey that the wife was 
not able to provide the proper care and diet required by the patient's physical 
condition, and what he needed was institutional convalescent care, followed by 
occupational placement. He was referred to those conducting a study of the 
handicapped, in progress at. the time, and employment suited to his condition was 
to be arranged for. 

Case No. 17 — A young woman of 21 with no family or home, who was in the 
hospital for over three weeks with heart disease, went to a rooming-house on dis- 
charge. She was working in a laundry, her legs and feet were swollen, and she 
felt she would soon have to return to the hospital again. This patient should 
have been in a convalescent institution where she would have the special medical 
supervision and be referred to an agency for assistance in obtaining work suited 
to her heart condition. • 

Occupational Therapy 

Throughout the hospitals of San Francisco there are but two occupa- 
tional aids, one each at the University of California, and the Lane and 
Stanford Hospitals. The well-known benefits to be obtained during; 
the period of bed care of hospital patients through the stimulation and 
direction of occupations, provided by trained persons acting under 
medical advice, for therapeutic purposes can hardly be said to be appre- 
ciated by the medical or administrative staffs of the hospitals of the city. 
Occupation of patients of almost all types appears to aid in recovery, to 
make easier ward management, to abbreviate the length of stay of patients, 
and assist in many ways functional repair, particularly in surgical and 
orthopedic cases and among psychiatric patients. 

It is understood that the salary of the occupational aid at Lane and 
Stanford Hospital is supposed to be a suitable burden for the Community 
Chest, and at University of California Hospital an appropriate item for 
the Women's Auxiliary to support. 

The position of occupational therapeutist or aid in a general hospital 
should be as definite and integral a part of the hospital staff, as is the 
anesthetist, the dietitian or the dentist. 

Instead of considering this a service only for the amusement of 
patients, and a matter of unconcern to the attending medical staff, this 
resource in the treatment of disease should be used intentionally by 
physicians and surgeons, by calling upon the occupational aid to plan 
for treatment as they do the serologist, the pharmacist and the dietitian. 



Services for the Sick 65 



While the simple occupations of bead work, jewelry, weaving and 
basketry serve to introduce the function of occupational therapy into 
the hospital household, they do not represent the full range and scope of 
manual trades, etc., which could be used with great advantage, especially 
among the 9 per cent of patients in San Francisco's Hospitals who have 
been bed patients for three months or more, many of them for several 
years. 

A study of the uses of occupational therapy as developed in many 
general hospitals throughout the United States would be an interesting and 
probably a profitable undertaking for the proposed Hospital Council. 
The experience of the Massachusetts General and the Children's Hospitals 
in Boston, of Bellevue Hospital in New York, of Barnes Hospital in St. 
Louis, and of the Presbyterian Hospital in Chicago would be illuminating 
and stimulating to any of the hospital executives of San Francisco who 
have opportunity for observation of hospital work elsewhere. 

Staff Conferences 

Attention should be called to the meager development among the ten 
hospitals, of clinical staff meetings. A few of the medical staffs meet with 
regularity and review certain phases of professional care, but such review 
cannot be considered to be complete if the conference programs are lim- 
ited to interesting or unusual cases, do not include the review of private 
patient's records, special patient groups and particular services, or do not 
include the presentation of cases which come to autopsy. 

The organization of staff conferences, which are intended to serve 
the purpose of a professional forum before which every record of service 
may be brought for searching analysis as to method and result of treat- 
ment, is perhaps the most important function of a medical board. 

Such conferences are growing steadily in value and suffer more from 
the lack of adequate preparation of the records upon which discussion 
must be based, than from indifference or lack of recognition of their 
worth. The points which should receive more attention from the several 
staffs are: (a) The use and results of consultant services where special 
problems of diagnosis and treatment are present; (b) The analysis of 
cause of death, particularly in obstetrical services and after operations of 
choice; (c) Infections following "clean" operations, post-operative pneu- 
monia, etc.; (d) Unsatisfactory results of treatment requiring readmis- 
sion, and (e) Complications which might have been avoided. 

It does not appear that the weekly colloquia conducted separately by 
the different services of the two university staffs at the San Francisco 
Hospital meet all the requirements of staff review of professional per- 
formance. 

Autopsies 

One way of measuring the interest in and practice of scientific clinical 
medicine is by the percentage of deaths that come to autopsy. Where there 
is indifference as to the accuracy of diagnosis, or what Dr. Richard Cabot 



66 Hospital and Health Survey 



so tersely described as the "sins of omission and commission/' we find that 
little attention is paid to that final verification of medical skill or the 
humbling process of facing one's own error which can take place only 
at the post-mortem examination. 

During 1922 according to the answers received from the hospitals by 
the Survey no autopsies were performed at St. Luke's, Mary's Help, or 
Mount Zion Hospitals among the 336 deaths which occurred in these 
institutions in the year. Apparently there were no autopsies performed 
at the French Hospital, the number of deaths, however, being omitted 
from the report from this hospital. 

At the Franklin and St. Mary's Hospitals autopsies were performed 
in 1.9 per cent or four of the 208 deaths, and 8.1 per cent or eleven of 
the 135 deaths, respectively. At the Children's Hospital autopsies were 
performed in 39.5 per cent (sixty out of 152 deaths). At the three hospi- 
tals used for teaching purposes, with the attending stafTs nominated by 
the medical schools, autopsies were performed as follows in 1922: 

Deaths Autopsies Per cent 

San Francisco Hospital 599 137 22.8 

Lane and Stanford.... 252 44 17.4 

University of California . * . 42.0 

Making all suitable concessions for racial and religious prejudices and 
superstitions, it cannot be said that this is a good showing. There is 
little resourcefulness or determination used in securing consent for post- 
mortem examinations. This is distinctly a function of the hospital ad- 
ministration, although interest and persistence on the part of the at- 
tending and resident staff is a powerful aid to success. When the Mon- 
treal General Hospital, Peter Bent Brigham Hospital in Boston and 
Mount Sinai Hospital in New York can obtain consents for autopsies in 
over 85 per cent of the deaths there ought to be more than one hospital 
in San Francisco to claim as much as 42 per cent of autopsies. 

(d) AREAS SERVED 

Although the majority of the hospitals have some general idea of 
the sections from which they draw their patients, there is no definite 
knowledge on the subject as no studies have been made which would fur- 
nish these facts. In order to obtain information from which deductions 
could be drawn regarding the areas served by the several institutions, a 
study was made of the addresses of 6542 patients — representing the cases 
admitted to the ten hospitals during two months, November, 1922, and 
January, 1923. 

The results of this study indicated that 84 per cent of the patients 
admitted during the period were residents of the city and 16 per cent 
were non-residents, the percentages varying for the individual hospitals, as 
follows : 



Services for the Sick 67 



Percentage of Residents Among Hospital Admissions, November, 1922, 

and January, 1923 . 

Percentage from 

San Francisco 
Public Institutions — 

San Francisco Hospital 99 

University of California Hospital. . . 64 

(21 per cent no address or wrong address.) 

Privately Controlled Institutions — 

Children's Hospital 80 

Franklin Hospital 80 

French Hospital 91 

Lane and Stanford University Hospital 65 

Mary's Help Hospital 90 

Mount Zion Hospital 89 

St. Luke's Hospital 84 

St. Mary's Hospital 78 

Average 84 per cent. 



68 Hospital and Health Survey 



In order to ascertain the specific areas served by each hospital, in- 
dividual maps were prepared showing the geographical distribution of the 
patients admitted to each institution during the period specified. Based 
upon the results of this further study, the general areas served by the 
several hospitals are herewith briefly outlined: 

Of the two public institutions, the San Francisco Hospital serves 
primarily the Potrero and Mission districts, the Western Addition, and 
those sections south of Market Street which border on the general neigh- 
borhood of the hospital; the University of California Hospital serving its 
own immediate locality and the section bounded by Stanyan, Seventeenth, 
Turk and Fillmore Streets, largely. The admissions tx> the first-named 
institution constituting the largest number of free patients cared for dur- 
ing the period studied, a further analysis was made of the sections served 
by this hospital, as shown in Map 2, page 69. As the city is not divided 
into the usual municipal health districts, the districts used are those com- 
monly used in designating the various sections of the city. 

Of the privately controlled hospitals, the Children's Hospital appar- 
ently serves all sections of the city, with the exception of the Potrero 
district. There does not appear to be any particular section which is 
served more than any other, the number of patients coming from the 
different parts of the city varying with the density of population. 

The Franklin Hospital admitted patients from all sections of the city, 
there appearing to be no particular district served more than any other. 

The patients admitted to the French Hospital came chiefly from the 
district bounded by Fillmore, Market and Larkin Streets, the neighbor- 
hood of Telegraph Hill and from its own neighborhood. 

At Lane and Stanford University Hospital, though patients were 
admitted in large numbers from all sections of the city, the section 
served appears to be primarily that in which the institution is located. 

Mary's Help Hospital serves chiefly its own immediate district — a fact 
which was also true of its dispensary service, based upon the addresses 
of new dispensary patients admitted during the same period. 

Mount Zion Hospital, while admitting patients from all sections of 
the city, serves the general area north of Market Street out as far 
as Golden Gate Park, the great majority of the patients living in the 
section bounded by Market, Fillmore, Geary and Larkin Streets, and a, 
large number coming from the hospital's own neighborhood. At this 
hospital, also, the new dispensary patients during the two months studied, 
came chiefly from the same general districts as the hospital cases. 

At Saint Mary's Hospital, the greatest number of patients came from 
the hospital's own section of the city, although many of them were ad- 
mitted from the general metropolitan area. 

St. Luke's Hospital serves all parts of the city excepting the extreme 
western and eastern portions, the striking fact being the uniformity 
with which patients were received from all sections. 



* 

$ 



5: 




Auwnoo OJUVA/ MVP 



70 Hospital and Health Survey 



These combined data reflect general and special areas served by the 
individual hospitals. It is to be expected that the two University hospitals 
admit patients from all sections and that most of the other institutions 
serve their own localities to varying degrees. The facts indicate that many 
of the hospitals draw from practically all sections of the city, and that 
Marys Help, Mount Zion and St. Luke's Hospitals receive patients in 
reater proportion from their own neighborhoods. 



« > 



HOSPITAL FINANCES 

Of the two publicly maintained hospitals the San Francisco Hospital, 
supported by city taxes, has made no request for community support 
from the Chest. Matters of finance at this institution therefore were not 
considered by the Survey. 

The University of California Hospital, supported by fees from 
patients, State taxes and income from endowments, furnished the Survey 
with a brief financial statement indicating the sources of income, and a 
total, but no items of expenditures. 

Of the privately controlled institutions, the Children's, Mount Zion, 
St. Luke's, Mary's Help, St. Mary's and Lane and Stanford University 
Hospitals are supported by donations from the public, income from opera- 
tion and interest on investments; St. Mary's and Mary's Help Hospitals 
receiving additional contributions represented by the services donated by 
Sisters. 

The two remaining private institutions, the Franklin and French 
Hospitals, are the activities of mutual benefit insurance associations, and 
in addition to the income from operation, donations, etc., receive support 
from their respective actuarial memberships. 

During the last fiscal years of the ten hospitals the total hospital 
income, including $713,000 expended for the maintenance of the San 
Francisco Hospital, amounted to $3,794,598.01. The several sources from 
which this sum was obtained were not clearly indicated in the financial 
information furnished, due largely to dissimilar accounting methods. The 
following table presents the facts in as much detail as the figures furnished 
permitted : 



Services for the Sick 



71 



Sources of Hospital Income, 1922 



Public 
Taxes 



Earnings 

from 
Operation 



Donations, 
Interest on 

Endow- 
ments, etc. 



Public Institutions — 



San Francisco ..$713,000.00 

University of California. 176,505.23 



$339,301.09 $11,414.38 



Total 
Income 



$713,000.00 
527,220.70 



Totals $889,505.23 $339,301.09 $11,414.38 $1,240,220.70 



Privately Controlled Institutions — 

Children's 

Franklin 

French (Society and Hos- 
pital income not sepa- 
rated) 

Lane and Stanford Uni- 
versity 

Mary's Help 

Mount Zion 

St. Luke's 

St. Mary's 



265,073.90 
369,863.46 



265,073.90 
369,863.46 



233,395.46 

534,353.08 
167,102.41 
350,028.94 
327,440.84 
307,119.22 

Totals $2,147,762.05 $173,219.80 $2,554,377.31 



534,353.08 
152,402.41 
249,590.41 
292,759.57 
283,719.22 



14,700.00 

100,438.53 

34,681.27 

23,400.00 



Grand Totals. 



$889,505.23 $2,487,063.14 $184,634.18 $3,794,598,01 
*(25%) *'(70%) *(5%) *(10O%) 



The foregoing is assumed to be indicative of the general situation 
regarding the sources of hospital income. It is probable that the con- 
siderable donations and endowment fund income of the Children's Hospi- 
tal, which do not appear on the foregoing table, would not materially 
increase the percentage of total income thus derived, as they would be 
largely offset by the income from operation of the French Hospital — an 
item which also was not furnished the Survey. 

Special mention should be made of the matter of the free services 
donated by the Sisterhoods conducting St. Mary's and Mary's Help 
Hospitals. As Sisters' services represent a financial saving to a hospital, 
the actual money equivalent should be estimated and listed as a donation 
from the Sister personnel. The amounts, therefore, listed as income from 
donations at St. Mary's and Mary's Help Hospitals represent the money 
equivalent of donated Sisters' services, and were computed by the 
Survey on the basis of current salaries for the positions held by Sisters 
in these two hospitals. The importance of the contribution of the Sister- 
hoods maintaining the two hospitals does not receive due recognition 
unless this is done. In securing cost items for purposes of comparing 
costs with those of other institutions, such estimates should be included as 
salary items, and, in recognition of the services donated free by the 
Sister personnel, they should be included in public statements of funds, 
contributions, materials, etc., donated to these hospitals. 



♦French Hospital income eliminated in finding- percentages. 



72 Hospital and Health Survey 



The finances of the French and Franklin Hospitals present special 
problems as these two institutions are essentially the undertakings of 
mutual benefit organizations. As the French Hospital did not furnish 
the Survey with the financial information supplied by other institutions, the 
facts reviewed were those contained in the organization's last- published 
report. These indicate that the hospital and Benevolent Society are con- 
ducted as a unit and that the undertaking for the fiscal year, ended in 
March, 1923, showed a profit of some $14,000. The facts furnished b^ 
Franklin Hospital indicate that the institution is a subsidiary of the 
German General Benevolent Society, to which rental is paid for the use 
of the hospital plant. For 1922 the hospital showed a net profit from 
operation of $545, which sum was applied to the reduction of the $34,000 
deficit arising through the mutual insurance activities of the Society. 

The total expenditures of the ten institutions during 1922, amounting 
to $3,752,412.70, is shown for the individual hospitals as follows: 

Hospital Expenditures, 1922 

Public Institutions — 

San Francisco Hospital $ 713,000.00 

University of California Hospital 527,220.70 

Total $1,240,220.70 

Privately Controlled Institutions — 

Children's Hospital , 280,433.18 

Franklin Hospital . . 369,317.47 

French Hospital (Society expenses included) 219,303.19 

Lane and Stanford University Hospital 585,419.38 

Mary's Help Hospital 152,109.02 

Mount Zion Hospital 335,607.40 

St. Luke's Hospital 317,490.74 

St. Mary's Hospital 252,511.62 

Total $2,512,192.00 

Grand Total . . .......; $3,752,412.70 

Due to the incompleteness and the differences of classification of 
expense items, it was not possible to analyze the relative amounts expended 
for the various items of hospital maintenance. These are important as 
indications both of service given and administrative policy, in that they 
show the amounts expended for the various phases of hospital work. 

The following table showing the relative percentage of the total 
expenses for each of the eight principal items of hospital operation, in 
a group of seven hospitals recently studied in New York City, is here- 
with presented as an indication of the precentage analyses which are 
possible when the needed facts are available: 



Services for the Sick 



73 



Percentage Distribution of Expenditures by Eight Principal Items 

(Seven Hospitals — New York City) 



Hospital 


Salaries 


Medical 

and 
Surgical 
Supplies 


Clothing, 

Bedding, 

Misc. 


Provi- 
sions 


Post 
Stat'y, 
etc. 


Insurance 
Interest 
on Mort- 
gages and 
Loans 


Fuel, 
Light 
and 
Water 


Repairs on 
Buildings, 
Furniture, 
etc. 




Per cent 


Per cent 


Per cent 


Per cent 


Per cent 


Per cent 


Per cent 


Per cent 


No. 1 . . . 


. 16.9 


6.8 


6.4 


46.0 


1.4 


6.8 


7.8 


7.9 


No. 2... 


. 31.3 


11.5 


5.4 


33.2 


1.5 


.1 


7.7 


9.3 


No. 3... 


. 43.5 


7.5 


1.6 


22.0 


1.2 


.1 


11.8 


12.3 


No. 4... 


. 25.4 


7.8 


12.0 


26.3 


1.4 


3.7 


11.2 


12-.2 


No. 5... 


. 30.6 


14.4 


4.9 


25.4 


1.4 


5.4 


13.3 


4.6 


No. 6... 


. 26.4 


9.2 


6.3 


30.8 


1.6 


1.8 


10.8 


13.1 


No. 7... 


. 17.3 


4.4 


9.9 


48.8 


1.1 


.3 


12.9 


5.3 



It is evident that the effective use of such large and active invest- 
ments requires careful financial planning, including budgetary methods 
and modern cost accounting — in other words those financial policies and 
practices that are endorsed as sound and reasonable for the conduct of 
public trusts generally. 

The chief defect of the financial operation is the almost general 
absence of these evidences of financial planning. For example, although 
some of the hospitals, notably the University of California and Mount 
Zion Hospitals, make some use of budgetary methods, the information 
obtained indicates that, at the first named, departmental and general per 
capita costs do not enter largely into budget consideration and at the 
latter, that but three of the departments are operated on budgets. 

In hospital operation an adequate financial plan includes the deter- 
mination of an annual budget for each department based on its past 
performance, use and needs, and the co-ordination of these departmental 
budgets in a combined budget for the institution as a whole. It includes 
also consideration of the expenditure of funds for the purchase of new 
equipment, education of personnel, new activities, etc., as well as those 
for the routine operation of the institution. 

In order to make and carry out a comprehensive and effective financial 
plan it is necessary for each managing board to consider departmental 
reports of work done, monthly statements of receipts and expenditures, 
current departmental and per capita operating costs, and a comparative 
budget and expense statement. Although the hospital boards receive 
monthly financial reports, many of them showing departmental receipts 
and expenditures, these are not associated with analyses or records of 
work done and even in those institutions where they have been established, 
cost units do not appear to be reviewed. 

Accounting Systems 

The work of the Survey included the collection of only general 
facts regarding accounting methods and financial policies. 

It is recognized that there necessarily enter into the operation < of 
the University of California and Lane and Stanford University Hospitals 



74 Hospital and Health Survey 



complex questions of cost distribution, in order to determine hospital 
operating costs as differentiated from medical school operating costs. 

These costs are somewhat segregated at Lane and Stanford University 
and are now undergoing analysis and revision at the University of Cali- 
fornia, although general facts gathered at the latter suggest that as yet 
there has been no separation of the cost of private room patients and 
ward patients, and that the accounting system does not readily furnish 
unit per capita costs. 

Based on the facts ascertained, it is evident that the accounting 
systems of the majority of the hospitals are in general of the type 
considered satisfactory some years ago, but unsuited to many phases of 
present day hospital operation. 

All of the defects encountered are not common to each institution 
but there were sufficient evidences to indicate that among the deficiencies 
are, the lack of periodic audits, modern inventory methods, and operation 
on a cash rather than an accrual system. Some of the hospitals have 
their books audited regularly by certified public accountants. Others have 
excellent stores and inventory methods and in still others an accrual 
system is in effect. 

The varying methods of estimating free service in the different 
institutions further indicate the need for the introduction of modern cost 
methods. This is illustrated in the fact that more than one hospital bases 
the cash value of its free service on prices charged and not on cost. 
Thus, in one hospital, if a free patient, because of his condition, is placed 
in a separate room, the free work of the institution is credited with the 
scheduled price of the room, and not the cost of hospital maintenance ; 
conversely, when ward care for which $2.50 a day is charged is given 
free, the hospitals free work is credited with this amount instead of 
the actual per' capita cost, which is over $4. In another of the hospitals, 
laboratory examinations furnished free are listed in the hospital's free 
work at scheduled prices instead of at cost. It must be clear that if a 
room costing $4 a day to maintain is listed at $6 work of free service, 
or if laboratory examinations costing $1 are listed at $3 worth of free 
work, entirely fallacious totals are built up, bearing no relation to the 
actual cost of the free service furnished. We cannot give away some- 
thing we do not possess and we cannot give away $6 worth of care that 
costs but $4, nor $3 worth of laboratory service that costs but $1. The 
consensus of lay opinion would certainly be to the effect that public con- 
tributions for hospital care are made in order that free treatment will be 
available to those unable to pay the cost of hospital service, and that the 
only charge to the free account for that service which is rendered free, 
should be the actual cost to the hospital of such service. 

Probably the most general defect is that accounts are not kept 
with a view to careful self-analysis as to cost of work done, essentials 
of which are the cost of hospital operation as a whole, the cost of the 
operation of the different departments, and the unit costs of the various 
types of service. This information is essential in determining expendi- 



Services for the Sick 75 

tures, allocating waste, setting rates, measuring efficiency, and for purposes 
of comparison with other institutions conducting similar work. 

Of the unit costs, the one most important and generally most used, 
is the per capita per diem cost — the amount representing the average 
daily cost of caring" for one patient. Deductions based on this cost, 
to be of value, should be correlated with facts regarding hospital opera- 
tion, whether, for instance, a low per capita cost is due to poor equipment, 
many chronic patients, undue crowding, etc., or conversely, whether a 
high per capita cost is due to a low degree of use of the hospital's beds, 
to the maintenance of costly diagnostic and treatment facilities, to un- 
economical administration, etc. 

The per capita per diem costs herewith presented were furnished 
by the institutions, with the exception of St. Mary's and the French 
Hospitals, in which cases the costs were estimated by the Survey on the 
basis of the total number of days' care compared with the total cost of 
operation, this cost at the latter institution including expenditures for 
both the Society and the hospital. , 

In presenting these cost data, it should be understood that in many 
instances they represent a blanket cost for both private and ward patients, 
for which the facilities, services, and maintenance vary considerably. 
For example, when a hospital states that the per capita cost of its bed 
care is $5 or $6 a day for all patients, it does not mean that $5 or $6 a 
day is expended to maintain all classes of patients, whether in the wards 
or in private rooms. What it does mean is that patients paying high 
rates and receiving increased service, superior surroundings and more 
expensive foods, raise the average cost for the care of ward and 
semi-private patients for whom comparable provisions are not furnished, 
and does not represent the true cost of care given to the majority of 
free and part-pay patients. 



76 



Hospital and Health Survey 



The individual per capita per diem costs of the nine hospitals during 

1 ( )22, were as follows: 

Per Capita Per 
Hospitals Diem Costs 

Children's Hospital $4.77 - 

Franklin Hospital 4.86 

French Hospital 4.46 

Lane and Stanford University Hospital 4.85 

Mary's Help Hospital 4.08 

Mount Zion Hospital 7.04 

St. Luke's Hospital 6.74 

St. Mary's Hospital 4.43 

University of California Hospital 4.16 

These data, which show a wide range in the cost of hospital care, are 
pictured in Chart D, page 77 . 

Hospital Rates 

In view of the fact that there is considerable sentiment in San 
Francisco to the effect that the prices charged for bed care, laboratory 
services, and for special treatments, are in general high and provide 
small opportunity for hospitalization, diagnosis and treatment at moderate 
rates, information was collected relative to the current rates for children, 
adults and maternity patients and for laboratory examinations. 

It is believed that more complete facts might modify the figures 
derived from the information furnished, shown in the following table, 
but they represent a summary of the information as obtained from the 
hospitals on direct inquiry : 

Beds for Children (Medical and Surgical Conditions) 

Number of Beds Per Cent 

Under $2 a day 

$2 to $3 a day 114 .58 58 

$3 to $4 a day 23 12 

$4 to $5 a day 55 28 

Over $5 a day 2 2 42 

Beds for Adults (Medical and Surgical Conditions) 

Number of Beds Per Cent 

Under $2 a day 

$2 to $3 a day 15 1 

$3 to $4 a day 392 28 29 

$4 to $5 a day 420 30 

$5 to $10 a day 556 40 

Over $10 10 1 71 

Beds for Maternity Patients 

Under $3 a day 

$3 to $4 a day S3 23 

$4 to $5 a day 50 34 57 

$5 to $10 61 43 43 





















o 
o 
















8 


• 

00 

4fr 



















O 




















1 


o 

o 
















o 
o 


o 


• 
















I s -* 


o 






















CO 






















o 


o 
o 


















o 
o 


z 


• 

10 


















• 


< 






















cc 






















U_ 


o 


















o 


2 


o 

• 


















o 

• 


< 


to 




















m 


CO 
























z: 


o 
























o 




o 


























o 
4 


u 






























q: 






























< 






























CJ 


o 

o 


























o 
o 


-J 


>0 


























• 


< 






























t 






























Q_ 


o 


























o 


o 


o 


























o 


I 






























u. 


o 


























o 


o 


o 

• 

5 


























o 

• 


!— 






























CO 






























O 






























O 


c% 


























f> 


u 


\J 


(£-1 + 


+ <s 


1 to 


N- 


<s> ro 


<s 


' CO 


w 






-go 9 


t— OC 

IB 


> CO 

» • 


I s - 


• • 


4 


O 

• 




Ul 




cc 








































o 
















<-H 
















c 












c 
o 

3 


1 

; & 

1 jg c 

— 1 c 




ft. 

35 


g 2Z 




Q_ 




o 


55 IE 


_l 


IE 


Li_ <0 


E 


z: 



Q 
H 

K 
O 



78 Hospital and Health Survey 



While these facilities show a high percentage of accommodations at 
more than moderate rates — only about one-fourth of the facilities being 
offered at prices ranging from $21 to $28 a week — actually in practice 
these are at times waived to accommodate patients who cannot afford to 
pay the full cost of the scheduled rates. Many of the hospitals -allow 
discounts on bed care, laboratory examinations, special treatments, etc., 
some of these discounts being generous. Several patients visited during 
the course of the convalescent study of the Survey had not paid in full 
for their care, either for their ward or room beds, or for special and 
extensive diagnostic and treatment services required by their condition. 

P>ased upon the brief material available for study, it is evident that 
some adjustment in the rates is needed in order to serve equally all the 
economic groups of the population. The specific provisions which should 
be made can only be determined by a co-ordinated study on the part 
of the hospitals. The Survey has insufficient knowledge upon which to 
base conclusions of value except that, in view of the preponderance of 
facilities costing over $4 and $5 a day and the difficulty experienced 
by physicians and interested lay workers in hospitalizing part-pay patients, 
a further detailed study of the subject by the hospitals themselves appears 



urgent. 



Laboratory Charges 



One of the matters receiving attention from hospital authorities is 
the regulation of fees for laboratory examinations. The practice of charg- 
ing a separate fee for each examination is being discontinued and a flat 
fee to cover all pathological laboratory work is being substituted. This 
substitution has been introduced at the University of California, Mount 
Zion, and St. Mary's Hospitals. 

More recently leading hospital administrators are regarding the cost 
of laboratory work as a general hospital expense and discontinuing the 
charging of special and separate fees. In order that the cost of operating 
the laboratory department shall be met, the actual cost of maintaining 
the department is divided by the number of days of care furnished, the 
resulting small amount being added to the existing room or ward rate. 

Thus, a hospital may find that the total cost of its pathological 
laboratory, when spread over the total days of care, increases the cost 
by 25 cents per patient day. Rooms that were $4 a day are thus raised 
to $4.25 a day and no separate item for laboratory examinations appears 
on patients' bills. (Mount Sinai Hospital, Cleveland, an institution operat- 
ing extensive laboratory departments, estimates the cost of its pathological 
laboratory at 16 cents per patient day.) 

Similar methods for apportioning the cost of X-ray examinations 
have been adopted to only a small extent, although recognized as correct 
in principle. The amount which will be required to meet the cost of a 
hospital's X-ray department can be fairly well determined by predicating 
cost and volume of work upon the last six months' or years' experience 
of the department's activities and cost of operation. 



Services for the Sick 



79 



"Hospital operation at present shows similar instances of cost dis- 
tribution. Thus, no separate charge is made for the services of a dietitian, 
although the treatment of individual patients frequently requires con- 
siderable time and attention from dietary departments. Again, hospitals 
make no charge for the services furnished by social service departments, 
although these also are available and used for other than free patients. 
There is no apparent reason why a patient should pay for an examination 
of his blood, which is one phase of hospital service, any more than for 
the services of a dietitian, or of a social service worker. 

It must be obvious that the determination of the amount which should 
be added to the daily rate to cover laboratory costs when distributed as 
a general cost, can only be undertaken when the individual operating costs 
of laboratory departments are known. 

Even a brief review of the laboratory rates now charged in the nine 
hospitals indicates that some are out of all proportion to the cost and are 
comparable to those charged in commercial laboratories which naturally 
expect to make a good profit. Thus a rate of $5 for a Wassermann test — 
an examination which costs from 20 cents to 30 cents in a well-managed 
laboratory — is excessive. In X-ray departments likewise, in many in- 
stances, the prices charged are not based on cost, even for dispensary 
patients. For example, the price charged for an X-ray examination of 
a hand, arm or finger — $5 to $10 in some of the hospitals — shows a con- 
siderable margin of profit. This is also true regarding X-ray examinations 
of teeth, the price varying from $5 for complete X-ray with $1 for one 
tooth, to $15 for complete X-ray, with $2.50 for one tooth. 

The adoption of a policy of "no extras" on patients' bills for these 
scientific examinations is desirable and should be agreed to. San Fran- 
cisco hospitals have here an opportunity to crystallize hospital opinion 
by the adoption of a program which will provide examinations and treat- 
ments upon a basis of diagnostic and therapeutic necessity, rather than on 
an arbitrarily determined economic basis. 

SUMMARY 

It is clear that these ten hospitals, founded upon definite needs in 
the community life, constitute a dominant factor in the work of the city 
for the care of the sick. Their boards and staffs are responsible for the 
medical standards surrounding the care of at least three-quarters of the 
city's sick who enter hospitals and over 90 per cent of those who receive 
dispensary service. 

This intimate contact with thousands of the population ofifers enviable 
opportunities for the care of the sick, the prevention of sickness and the 
promotion of health, matters which the progress of medicine renders 
yearly of increasing importance. Institutions which, like these ten hos- 
pitals, are spending millions of dollars annually for such purposes, need 
not only managing boards which concern themselves with the details of 
administering particular institutions, but also a central body free to think 
out those broader policies which will increase the efficiency of health and 



80 Hospital and Heai/th Survey 



medical work throughout the community and enable every dollar to 
bring the greatest return. 

In the opinion of the Survey, the chief lack in the San Francisco 
hospital field is the absence of contact among the individual units of 
this large community undertaking. The institutions, with common aims 
of public service, have no unifying organization or program for the. 
effective accomplishment of the work in which they are each individually 
engaged, nor is there a central authoritative group equipped to study 
particular problems and plan for their solution. 

There is needed a well-organized co-operative group which could 
formulate general standards, suggest policies and determine programs for 
dealing with the particular problems of the hospitals of San Francisco. 

The need for some plan for co-operation is appreciated. The general 
sentiment among hospital boards and executives favors a commonsense 
working basis for the co-ordination of hospital policy and of certain 
aspects of hospital administration, the elimination of known duplications 
and wastes and for the mutual benefit which would result from unified 
effort and joint planning. 

Hospital Council 

The success of joint councils suggests that the hospitals would derive 
benefits and stimulus from the establishment of a Hospital Council — in 
fact every indication for progress points toward the advisability and 
practicability of such a co-operative effort. 

A Hospital Council, properly organized, would leave undisturbed the 
executive powers of the individual hospitals, and provide a central ad- 
visory and co-operative service; the Council to serve primarily as a 
volunteer organization for the development of improved hospital service 
and economy of hospital operation, to enjoy delegated powers only, and 
to influence hospital affairs through the confidence which it inspires 
and the authority thus established. 

Such a Council should include representatives of the boards and the 
executives of all the hospitals of the city and men and women from pro- 
fessional and business groups, as follows: 

(a) One member from the board of each hospital. 

(b) The hospital executives. 

(c) Additional members at large to include preferably a representa- 
tive of the County Medical Society, a lawyer, a financier, an accountant, 
a representative of the Council of Social Agencies and several women of 
broad interests, one of them, preferably, an educator. 

Such an organization would enable the experience of each institution 
to be of benefit to all and would break down the tendency to isolation 
which is characteristic of institutions without a central co-ordinating 
organization. 



Services for the Sick 81 



To be effective, the Council should organize with officers and com- 
mittees, and provide for at least monthly meetings. The more important 
standing committees should be appointed, and provision made for the 
appointment as needed of special advisory or study committees with extra- 
Council membership. 

In order to accomplish results and obtain the fullest advantage 
accruing from co-ordinated effort and pooled experience, it is essential 
that the Council employ an ably equipped, whole-time executive secretary. 

The initial Council activity which could be undertaken with advantage, 
and which would render immediate services to the hospitals is a central 
purchasing department. 

The experience of the Cleveland Hospital Council is indicative of 
the large benefits accompanying the establishment of such a co-operative 
service. During 1922 over $700,000 was expended by its purchasing 
bureau, with great saving to the hospitals and other institutions, and 
much improvement of service in the matter of deliveries, etc. 

Not the least important use of a centralized purchasing system is 
the expert advisory service made available for studying market conditions, 
contracts, etc. 

It would probably be necessary to establish an initial revolving fund 
so that cash discounts might be taken. The saving thus effected would, 
for the eight private hospitals alone, be considerable. During 1922, less 
than $1000 was thus earned, although experience demonstrates that cash 
discounts will equal one-half of one per cent of the total expenditures of 
hospital operations — an amount in the eight hospitals of approximately 
$12,500. 

In addition the following problems, regarding which there already 
exists considerable knowledge and opinion, warrant early group attention : 

(a) There is need for the establishment of uniform standards for 
reporting those medical administrative and financial statistics recognized 
as essential as a basis for guiding medical, financial and administrative 
policies. The monthly report form adopted by the Cleveland Hospital 
Council for reporting similar facts to the Cleveland Welfare Federation 
appended to this report (see page 145, Section V) gives the items which 
should be collected. 

(b) A study of hospital rates, with special reference to the needs 
of families of moderate means, correlated with facts as to part-pay patients 
admitted and those applying and not admitted, all assembled uniformly 
by all' the hospitals would furnish a basis upon which to determine 
the provision which must be made. 

In this connection, consideration should be given to the question 
of the establishment of part pay facilities at the San Francisco Hospital, 
as furnished by municipal hospitals in other cities — notably Bellevue 
Hospital, New York City, and the Buffalo General Hospital, Buffalo, N. Y. 

(c) There is need for more complete information regarding the 



82 Hospital and Health Survey 



problems of the chronically sick. The collection of facts on this subject 
over a considerable period would provide a basis for determining the 
extent of the need and for suggesting a program to meet it. 

(d) The economy of a central collection service to which unpaid 
hospital accounts could be turned over for collection is a subject requiring 
particular study. A similar service instituted two years ago by the 
Cleveland Hospital Council 7 has four main objects: "1. Collect 'col- 
lectable' accounts at the lowest cost. 2. Prevent 'Current' accounts from 
becoming 'dead' accounts and reduce to a minimum amounts charged 
off as 'accounts uncollectable.' 3. Fix the status of every account within 
six months as 'collectable/ 'uncollectable' or 'collected.' 4. Reduce 
amounts to be charged off to a minimum every six months." 

(e) The question of obtaining recruits for the schools of nursing 
is a problem in almost every one of the hospitals. This important sub- 
ject deserves the attention of a special committee or a permanent sub- 
committee, representative of all the training schools and various profes- 
sional nursing groups. It would naturally concern itself with such matters 
as the formulation of a program to reach high schools, normal schools, 
and women's colleges, direct attention to the excellencies and special 
opportunities of the various schools and would be effective in focusing 
attention on questions of group instruction during the preliminary period, 
need for opportunity in visiting nursing, the non-educational and non- 
nursing work now performed by student nurses in the hospitals, and the 
need for practical experience now lacking, such as medical social service, 
communicable disease nursing, including tuberculosis and venereal dis- 
eases, etc. 

(f) The question of hospital personnel, the ratio of personnel to 
patients, the establishment of standards for salaries, wages, hours of work, 
and provisions for initial and periodic health examinations of hospital 
workers in order that the sick will be surrounded only by the well, are 
matters which would benefit through persistent study. 

(g) Co-operative relationships should be established with the leaders 
in the Chinese health movement in San Francisco, with particular refer- 
ence to the plans now developing for a hospital and dispensary for the 
Chinese, under Chinese direction and control. 

(h) Benefit would result from collective attention to matters of 
hospital administration. There are at present unsolved problems which 
need careful consideration. The publication of annual reports, member- 
ship in national associations, attendance at national conferences and meet- 
ings of hospital executives and department heads, departmental organiza- 
tion, reports of work done, personnel, salvage, sale of materials, the use 
of labor-saving devices, etc., stores procedures, repair of surgical equip- 
ment and appliances, and similar subjects, are all worthy of study in the 
interest of hospital economy and good public service. 



7 The Cleveland Hospital and Health Survey — Two Years After. Cleveland Hospital 

noil 1Q91.1Q99 



Council, 1921-1922. 



Services for the Sick 83 



Chapter 2 

DISPENSARIES 

The organized dispensary service of the city is furnished by nine 
institutions, six of them hospital out-patient departments and three of 
them independent organizations : 

Hospital Dispensaries 

University of California Hospital. 

Children's Hospital. 

Lane and Stanford University Hospital 

Mary's Help Hospital. 

Mount Zion Hospital. 

St. Luke's Hospital. 

Independent Dispensaries 

Homeopathic Clinic. 
San Francisco Polyclinic. 

San Francisco Neighborhood Association, conducting the dispensary com- 
monly called Telegraph Hill. 

In addition to the foregoing, occasional clinic sessions for general 
and special patient groups are conducted by St. Mary's and the San 
Francisco Hospitals, and consultation or treatment hours are held at 
regular times by the Franklin and French Hospitals, Although these 
four institutions have at their command the supplementary services re- 
quired for adequate medical care, they cannot properly be classed as 
affording dispensary service in the present day meaning of the term. 
The Osteopathic Clinic, lacking adequate provision for diagnosis and 
treatment, is not here included. 

The dispensary facilities at these nine institutions are indicated by 
the number of clinic sessions held weekly and the number of hours of 
service offered. The number of clinic sessions held weekly during 
the morning, afternoon and evening hours, are as follows : 



84 Hospital and Health Survey 



Dispensary Facilities of San Francisco 

Number of Clinic Sessions Weekly 

Total Morning Afternoon Evening 
Sessions Sessions Sessions Sessions 

Hospital Dispensaries 

Public Institutions — 

University of California 129 87 36 6 

Privately Controlled Institutions — 

Children's 48 42 6 

Lane and Stanford University 67 54 12 1 

Mary's Help 57 57 

Mount Zion 73 67 6 

St. Luke's 50 41 9 

Totals 295 261 33 1 

Independent Dispensaries 

Homeopathic 28 27 1 

Polyclinic 51 51 

Telegraph Hill 21 2 19 

Totals IOC 80 20 

Grand Totals 524 428 89 7 

The foregoing table does not include the following: (a) the morn- 
ing, afternoon and evening office hours held by salaried physicians of the 
Franklin and French Hospitals, chiefly for members of the mutual benefit 
associations conducting the two hospitals; (b) the Orthopedic Clinic con- 
ducted by St. Mary's Hospital three mornings weekly; and (c) the five 
morning and one evening Chest Clinics and the one afternoon Prenatal 
Clinic held at the San Francisco Hospital weekly. 

The scheduled number of hours weekly, represented by the 524 
clinic sessions, are shown in the following table : 



Services for the Sick 85 



Dispensary Facilities of San Francisco 

Number of Clinic Hours Weekly 

Total Morning Afternoon Evening 

Hours Hours Hours Hours 

No. Pet. No. Pet. No. Pet. No. Pet. 

Hospital Dispensaries 

Public Institutions — 

University of California 336 27 258 25 72 38 6 75 

Privately Controlled Institutions — 

Children's 78 6 60 6 18 10 

Lane and Stanford University 196 16 172 17 22 12 2 25 

Marv's Help 171 14 171 17 

Mount Zion 208 17 197 19 11 6 

St. Luke's 81 7 69 6 12 6 

Total 734 60 669 65 63 34 2 25 

Independent Dispensaries 

Homeopathic ' 45 3 44 4.5 1 .5 

Polyclinic 56 5 56 5 

Telegraph Hill 56 5 4 .5 52 27.5 .. 

Total 157 13 104 10 53 28 

Grand Total 1227 100 1031 100 188 100 8 100 



86 Hospital and Health Survey 

As 91 per cent of the clinic sessions shown in the preceding table 
are scheduled for the working hours of the day, they afford small oppor- 
tunity for dispensary care in the free time of wage earning groups, one 
of the groups for which dispensary service is chiefly maintained. 

The concentration of the clinic sessions in the morning hours, pic- 
tured in Chart E, page 87, represents a considerable unused investment 
in dispensary space and equipment. It will be seen that, although some of 
the institutions use their plants for a few afternoon clinics, practically no 
use is made of them during the evening. 

The number of physician-hours of service actually provided per 
100,000 of population — the correct basis for estimating hours of dis- 
pensary service — is not possible until physicians' registries are used 
uniformly in each institution. With such facts available, analyses can 
be made by the individual dispensaries of the amount of physicians' time 
devoted to original and return patients. 

MEDICAL SERVICES PROVIDED 

From the standpoint of medical care, the character and type of 
medical services offered are reflected in the facilities provided for general 
and special patient groups, and the number of hours available for each 
group. These facts are shown in the accompanying table : 



CO 

a. 
D 
O 

I 

o 
t# 

<M 



(0 

or 

D 

O 
I 

o 

CM 



O 

a 






l_U 



UJ 



o 

Cvi 
C\J 



O 

o 



o 





o 



O 
CM 
CM 



O 



o 

CD 



O 
<9 



CL 
Q 



o 



o 



O 

O 
CO 

o 



Lu 



< 

CO 



o 

CM 



O 
O 



o 

CM 



o 
o 



<: 

k 
o 



Q 

Ld 

Ld 



o 

CD 



o 

CO 



f0 

Ld 

o 

UJ 

CO 



CO 

o 

X 



o 

(0 



o 

to 
a 



s 



o 



o 

t 

o 

cr 

O 
I 

O 
CM 



-II 






8K1 



**1 



t 



N 






CM CM 



o <5 

<o^- 

t-LZ. 
V cs 

c 
=3 



c 
o 

N 



cs 



Oi cvi o 

f 



OCO Q 



M> o o 






J. 

•I' 



CO 

X 

CS 

z 



-J 



c 


-15 



o 



c 
Cf 



-♦- 


_c 


«s 


-a. 


a. 


cs 


o 


£ 


V 


<57 


E 


CO 


o 
X 


t* 



88 



HoSPITAIv AND HeAI/TH SURVEY 



Weekly Hours of Dispensary Services to Patient Groups 



Hospital Dispensaries ^ 

Public Privately Controlled 



Independent — 
Dispensaries 



General Medicine 

A.M. ... 

P. M. 
General Surgery 

A. M. . . , 

P.M. ... 
Pediatrics 

A.M. ... 

P.M. .. 
Gynecology 

A.M. .. 

P. M. ... 
Eye, Ear, Nose and 
Throat 

A. M 

P. M. 

Genito-Urinary and 
Urological 

A. M 

Eve 

Venereal Disease 

A. M 

Eve 

Orthopedic 

A. M. 

Neurological and 
Mental 

A.M. .. 

P.M. .. 
Dental 

A.M. .. 

P.M. .. 
Prenatal 

A.M. .. 

P.M. .. 
Dermatology 

A.M. ... 

P. M. . . . 
Heart 

A.M. ... 
Physiotherapy 

A. M. ... 

P.M. ... 
Tuberculosis 

A.M. ... 
P.M. ... 



Totals 
A.M. 
P.M. 
Eve. 



d 
p 



o 
p 

P 
P 



33 
12 

18 

12 



18 



36 
12 



12 
18 

• • 

18 

18 
12 



o 

P 
i-i. 

P 

02 



18 
3 

18 



18 1 



18 
4 

• • 

3 



P 

a> 

so 
P 
P* 

ui 

r+ 

P 
P 

o 
*i 

P. 



18 24 



p 

02* 

w 

►— ■ 

•d 



o 
p 
p 

N 
>— i. 

o 
P 



It 1 

p 

02* 



o 

«-t- 

P 
i— i 

w 

o 

p 

•-S 
02 



o 



o 
d 

P 



o 



12 10 106 
.. 2 14 



18 



18 18 18 12 90 
.. .. .. 2 14 



18 18 18 6 78 10 



36 



13 



36 10 124 
. . 2 27 



18 1 18 



18 



18 



18 
3 



67 



18 

5 

59 



52 
4 



18 15 27 18 10 88 



3 
2 

18 



8 
6 

• • 

18 



3 
1 

2 

1 



12 



26 

19 
15 

59 
1 

18 

30 
12 

15 
3 



o 

o 

I— '• 

p 
o 



8 



3 8 



,. 2 

> • • • 

2 6 

i • • • 

2 1 

• • • . • 

2 2 



• • 



258 60 172 171 
72 18 22 .. 
6 . . 2 



194 69 924 

14 12 138 

2 .. 8 



H 

a> 
i— " 

p 
d 
P- 

K 



28 



18 12 22 19 20 11 101 4 6 2 
12 3 3 22 .... 14 



44 56 4 
1 .. 52 



o 

P 



Total 

Hours 

Weekly 



M 

o 

p 

02 




24 


130 


• • 


14 


11 


101 


28 


42 


12 


113 


14 


36 


16 


94 


2 


2 


9 


133 


7 


34 


11 


78 


• • 


3 


• • 


18 


• • 


5 



61 



2 

• • 


54 
4 


8 

• • 


96 
26 


3 

2 


22 
17 


4 

• * 


63 

1 


• • 


18 


• • 

• • 


30 
12 


2 

• • 


17 
3 


104 

53 

• • 


1028 

191 

8 



Q_ 

Z) 

o 
o 



UJ 

q en 

LlI u_ 
cr 

uj -z. 

v- < 



¥ 



</)0 

X 
lu 



s 

> 

1/3 

flt 

o, 
IS 

o 

t 

V. 

u 
I- 
u. 



(ft 

at 

3 



5 

(XL 



O 






c 



-<5 



g 

C 
Q) 

O 



3 



3 

o 

X 

o 
in 



ooo^^r^ioooo^^ooo 



a 



>^s Oj CS) C\J > o o 

< ro i*> ro 



Ci M* CO 



N. *^ <^ C\J ^> 



I 



I 



i_U 






oo O K 

<: ro < 



8 



3 
O 



o 






Q) 

D 
CO 



0) 
C 
Q> 

CD 






L. 

is 

d? 



& 



o 

o 

E 



<5 

8 



C 

cs 

O 



i3 



-5 

c 



Q) 
-_0 Q 



<3 ^ <0 



o 



I 



o 












c 

Q> 



c 



o 



f 



CD 

o o JS 



5 -r 



o 



3 



C 

Q) 

Q 



i 

efc 



E 

Q) 
O 







*J> 






<o 






o 






-C 






O 






v^ 




£> 


«0 




<S 






c 


</> 




0J 


o 




-c 


— 




-f- 


3 


4- 


o 








Q_ 


H2 



90 Hospital and Heai/th Survey 



The foregoing facts, also pictured in Chart F, page 89, not only 
emphasize the preponderance of morning clinic sessions and the meager 
provisions for afternoon and evening dispensary care, but also show 
that the provisions other than those available in the morning, are only 
for special patient groups. 

The range of general and special patient groups for which provision 
is made, indicates that dispensary service in San Francisco is well 
developed for the general services and, to a considerable degree for 
the more special services, but that there is need for further development of 
facilities for the supervision of pregnant women, patients with heart dis- 
ease, and those with venereal diseases. 

There should be some facilities for evening clinics for the benefit 
of persons with venereal diseases, cardiac patients, and for certain other 
patient groups who work. This would not necessitate having elaborate 
equipment, but would serve as a means of helping people improve in 
health by having a place where they could obtain medical care and 
treatment at cost, after working hours. 

Certain of the special clinics reflect commendable increasing hospital 
participation in sickness prevention and community health affairs. Among 
them might be mentioned the Posture Class at Lane and Stanford Uni- 
versity, the Well Baby Clinics at Telegraph Hill, Lane and Stanford 
University and Mount Zion, the Chest Clinics maintained by the Board 
of Health at the University of California, Telegraph Hill, Lane and Stan- 
ford University and Mount Zion, those for Orthodontia at Mary's Help, 
the clinics for school children held at Mount Zion, etc. Another develop- 
ment thoroughly in accord with modern health service, is the Health 
Examination Clinic for Adults at the University of California, now in 
process of formation. 

The lack of reciprocal medical records of patients referred from 
some of the hospitals to their out-patient departments or to independent 
dispensaries interferes with the continuity of medical care and hampers 
social follow-up of patients. The results of this lack are illustrated by the 
following case : 

Case No. 18 — A six and a half months' old baby in the hospital for two 
weeks with tonsillitis, otitis media, cystitis and cervical adenitis, was discharged 
as cured, the mother being told to take the child to an independent dispensary 
in her neighborhood so that a urine examination could be made weekly. The dis- 
pensary had received a telephone message from the hospital stating the patient 
had been discharged, but no medical history, diagnosis, treatment or notes as to 
further care were forwarded from the hospital. When the mother took the baby 
to the dispensary, she was referred to the well-baby clinic. As the physician 
in this clinic took up the matter of diet and weight and asked no questions 
which would have brought out the hospital history, nothing was known about 
the conditions for which the patient had been treated, or the further care ordered 
by the hospital doctor. The dispensary is not equipped to make urine exami- 
nations. 

Similarly, patients under dispensary supervision for long periods may 
be sent to hospitals for bed care without any advantage accruing to either 
the patients or the hospital doctors from the accumulated clinic expe- 



Services for the Sick 



91 



rience, due to the fact that the medical records of clinic care do not 
always accompany patients to hospitals. 

The foregoing defects are noticeable omissions in the medical care 
provided for patients admitted to the San Francisco Hospital who also 
attend the out-patient departments of the two university hospitals. These 
two hospitals have excellent reciprocal records for their own in and out- 
patient departments, but similar standards of medical supervision have not 
been instituted for their patients who are treated at the San "Francisco 
Hospital. 

ORGANIZATION AND EXECUTIVE CONTROL 

But two of the hospital dispensaries, the out-patient departments of 
Mary's Help and the University of California Hospital, approach, in 
organization and executive direction, the standards advocated for modern 
dispensary operation. At these institutions, most of the functions of man- 
agement of the dispensaries are centered in one individual whose chief 
responsibility is the direction of the department. 

At Lane and Stanford University the out-patient department is a 
department of the Medical School, and there is no one person charged with 
its management and giving it his main attention. 

At Mount Zion and Children's Hospitals, although the dispensaries 
are hospital departments, direction is not centered in individuals responsi- 
ble alone for the operation of the departments. As pointed out in the. 
chapter on Social Service, the work of the social service departments of 
these two hospitals is obscured by the dispensary executive responsibilities 
they carry. 

Of the independent dispensaries, the Board of Trustees of the Poly- 
clinic is composed entirely of physicians, an arrangement and in accord 
with approved standards of board organization. The administrative organ- 
ization is also not in agreement with the accepted principles of dispensary 
management, and does not furnish a basis for segregating dispensary costs 
as differentiated from those expenditures which relate essentially to the 
operation of its twelve-bed hospital unit, maintained chiefly for private 
patients. 

At Telegraph Hill Dispensary, an activity of the San Francisco 
Neighborhood Association and managed by its Board of Directors, the 
executive control of the clinics appears to be carried in part by a member 
of the board, and in part by a member of the salaried personnel. 

In view of the limited service of the Homeopathic Clinic and its small 
salaried staff, the principles of organization and management applicable to 
the other dispensaries do not appear to apply. 

Dispensary committees of directing boards — advocated in hospital 
operation as a practical means of dealing with dispensary problems — are 
undeveloped, Mount Zion Hospital alone having a functioning dispensary 
committee. 



92 Hospital and Health Survey 



It is evident that in the dispensary field, as in the hospital field, there 
is need for a general community plan to provide for the special economic 
and sickness groups to be served. A dispensary committee of the proposed 
Hospital Council, representing all the organized dispensary groups, would 
be an effective body to study the particular needs of the city's ambulatory 
sick, and formulate a program which would co-ordinate the various phases 
of the work now operating in unrelated units. 

SERVICES RENDERED BY DISPENSARIES 

In studying the extent of the dispensary service rendered, the main 
facts considered consisted of (a) the total number of visits for 1922, 
together with similar data for 1921; (b) the number of new patients 
applying in two representative months, November, 1922, and January, 
1923, and (c) the geographical districts served by the individual dis- 
pensaries, based on an analysis of the addresses of 5632 patients apply- 
ing at the nine dispensaries and the clinics of the San Francisco Hospital 
during the two foregoing months. 

(a) DISPENSARY ATTENDANCE— 1922 

During 1922, a total of 272,000 visits were made to the nine dis- 
pensaries, as follows : 

Dispensary Attendance — 1922 

Per Cent 
Number of Per Cent Gain or Loss 
Visits of Total 1921-1922 

Hospital Dispensaries 
Public Institutions — 

University of California 90,343 33 +1 

Privately Controlled Institutions — 

Children's 12,998 5 +2 

Lane and Stanford University 96,845 36 +12 

Mary's Help 11,749 4 +13 

Mount Zion 28,520 11 +14 

*St. Luke's : 11,281 4 + 54** 

Total 161,393 60 

Independent Dispensaries 

Homeopathic 1,664 1 

Polyclinic 10,419 3 +37 

Telegraph Hill 8,181 3 —32 

Total 20,264 7 — 5 

Grand Total 272,000 100 + 7 



♦Number of visits at St. Luke's includes 5332 visits to Canon Kip Memorial Clinic. 
♦♦Attendance at Canon Kip Memorial Clinic not included. 



Services for the Sick 



93 



Based upon the foregoing data, the total number of visits to the organ- 
ized dispensaries during 1922 indicate a ratio of about fifty visits per hun- 
dred of population. As the study of the addresses of the new patients 
indicated that 11 per cent were non-residents, (shown later in this chap- 
ter), the actual ratio for the city's population would more nearly approach 
forty-four visits per hundred. 

Comparison of this ratio with the ratios for other large cities is of 
interest : 

Ratio of Dispensary Visits to Population 

New York City (1919) ' 60 per 100 

Chicago (1918) 35 per 100 

Greater Boston (1919) 50 per 100 

Cleveland (1921) 26 per 100 

Montreal (1921) 45 per 100 

San Francisco (1922) 44 per 100 



94 Hospital and Heai/th Survey 

Using the estimate adopted by dispensary authorities — four visits per 
patient — it is assumed that some 68,000 persons sought dispensary care, 
about 60,500 of them being residents of the city. 

The percentage of total visits received by the individual dispensary, 
pictured in Chart G, page 95, indicates the importance of the services 
contributed by the two university dispensaries, the combined visits to these 
two institutions representing 70 per cent of the total dispensary attendance 
of the city for the year. Mount Zion received 11 per cent of the total 
visits, the other institutions, respectively, 5 per cent or less. 



CVJ 
OJ 

I 

o 
o 

CO 

o 

I 



< 

CO 



Ld 
U 

2 

Z 
LU 

I- 

!c 

>- 

I 

LJ 
CL 
tO 



o 
o 



o 



o 



o 

CM 



$ 



<0 












ro 
ro 



o 



to 



* 

* 






3, 






01 



S 

<\1 



St 



CO 
CVI 



<r 



J5 :§ z: 






MM 



O 
O 




? 



o 
to 



o 



o 



O 

U 



Y< 






<0 






o 






y> 


O 


_C 


4- 


V 


c 


Cl- 


<S 


D 


~o 




O 


.• 


_>> 


<u 


5 


& 


c£ 


£ 


o 



96 Hospital and Heai/th Survey 



The 90,000 visits made to the one publicly maintained dispensary indi- 
cate a ratio of 16 per 100 population. The dispensaries under city and 
State auspices in Buffalo, a city of similar size — 650,000 population — dur- 
ing 1922 received 192,213 visits, a ratio of 29 visits per 100 population. 

A tabulation of the monthly attendance at the six hospital dispen- 
saries, for the year 1922, indicated only slight seasonal variations in 
attendance, with the exception of a marked decrease in the number of 
visits during the month of February. These facts are shown in Chart H, 
page 97. 



> 



o 
o 
o 

ro 

OJ 



o 
o 
o 

OJ 
OJ 



o 

OJ 



o 
o 
o 

cT 

OJ 



o 

o 
o 

CD 



o 
o 

o 



o 
o 
o 



<£> 



o 
o 
o 

to 



o 
o 
o 



CO 




Ul 


t- 


a: 


b 

o 


< 




CO 




-z. 




ui 


*r 


Q_ 
(O 


Ul 

<0 


Q 




< OJ 


o 

< 


h- CD 




Q_ . 




CO 1 




?o 


5 


O 




* cO 




X T\ 




55 S 


U 


< 


c 
3 


ui cr 


«-> 


X Li_ 




1- 2: 




fe$ 


z 


. U_ 




UJ o 




CO 





o 

CO 

< 

Ul 

CO 




H 
< 

u 



to 


o 
o 


8 


O 
O 


O 

o 


o 
o 




o 


O 


O 


o 


o 




**• 


•» 








^> 


r> 


OJ 




o 


o> 




OJ 


<\J 


OJ 


OJ 





o 
o 
o 

CO 



o 
o 
o 



o 

c© 



O 

o 
o 

lO 



o 
o 
o 



98 Hospital and Health Survey 



The table of attendance also shows the percentage of increase or 
decrease in visits for the individual dispensaries, compared with similar 
data for 1921. The total number of visits for the nine dispensaries 
showed an increase of 7 per cent. Individual dispensaries showed much 
higher percentages of increase, St. Luke's having an increase of 54 per 
cent and Polyclinic 37 per cent; the only dispensary showing a decrease 
being Telegraph Hill, at which the attendance fell off 32 per cent during 
L922. 

(b) NEW DISPENSARY PATIENTS— TWO REPRESENTATIVE 

MONTHS 

As the number of new patients using a dispensary is one index of the 
extent to which it is used, tabulations were made of the addresses of the 
new patients who applied to the nine dispensaries and the clinics main- 
tained at the San Francisco Hospital during November, 1922, and January, 
1923, two months considered by local groups to be representative of the 
maximum monthly demand. This tabulation showed that during these two 
months 5632 new patients applied for dispensary care, as follows : 

New Dispensary Patients — November, 1922, and January, 1923 

Number Per Cent 
of Total 

Hospital Dispensaries 

Public Institutions — 

San Francisco 249 5 

University of California 1712 30 

Total • • 1961 35 

Privately Controlled Institutions — 

Children's 340 6 

Lane and Stanford University 1920 34 

Mary's Help 301 5 

Mount Zion 342 7 

St. Luke's •-.. 196 3 

Total 3099 55 

Independent Dispensaries 

Homeopathic 49 1 

Polyclinic 257 4 

Telegraph Hill 266 5 

Total V 572 10 

Grand Total 5632 100 

The University of California Hospital and the Chest and Prenatal 
Clinics at the San Francisco Hospital thus received 35 per cent of the 
new patients during the two months studied. The privately controlled dis- 



Services for the Sick 99 



pensaries received all told 65 per cent of the new patients, of which the 
five hospitals maintaining out-patient departments received 55 per cent, and 
the independent dispensaries 10 per cent. 

(c) AREAS SERVED BY DISPENSARIES 

The study made of the home addresses of the 5632 new patients was 
designed to ascertain two important facts,, namely, the extent to which the 
dispensaries are used by residents and non-residents of the city, and the 
areas served by each dispensary. 

The extent to which the dispensaries serve San Francisco is clearly 
indicated by the fact that, during the two months analyzed, 89 per cent of 
the new patients were residents of the city, and but 11 per cent non- 
residents. As shown in the following table, the Homeopathic and the Tele- 
graph Hill Dispensaries received no new patients from out of the city, the 
University of California Dispensary having the highest percentage of non- 
residents, 20 per cent of the total. As the last-named is a State institution, 
it is to be expected that there is at all times a certain percentage of non- 
resident patients applying for care. 

Percentage of City Residents 
New Dispensary Patients, November, 1922, and January, 1923 

New Patients Per Cent from 

San Francisco 
Hospital Dispensaries 
Public Institutions — 

San Francisco ■ 249 97 

University of California 1712 80 

Total 1961 82 

Privately Controlled Institutions — 

Children's 340 92 

Lane and Stanford University 1920 91 

Mary's Help 301 98 

Mount Zion 342 96 

St. Luke's 196 99 

Total 3099 93 

Independent Dispensaries 

Homeopathic 49 100 

Polyclinic 257 93 

Telegraph Hill 266 100 

Total 572 97 

Grand Total 5632 89 

If the experience of the two months is typical of the usual situation, 
there is need for a redistribution of the clinic facilities of the city, so 
that special or acceptable clinic care will be readily accessible to the eco- 
nomic groups for which dispensaries are primarily established. 



100 Hospital and Health Survey 



The present situation is indicated in Map 3, page 101, which shows 
the large percentage of dispensary patients from the Potrero and Inner 
Mission districts who traveled long distances to obtain the dispensary care 
they desired. Thus, only 28 per cent of the 1738 patients went to clinics 
within the two districts, 60 per cent going to the University of California 
and Lane and Stanford out-patient departments, the remaining 12 per 
rent attending the four other dispensaries located on the north side of 
Market Street. 

An analysis of the attendance at the nine dispensaries is of interest 
as showing the general areas served by the several institutions: 

University of California Hospital — Compared with the degree to which 
it draws patients from other sections of the city, this dispensary serves its 
own neighborhood to only a small extent. Patients are drawn in large 
numbers from distant sections ; thus, Telegraph Hill, the neighborhood of 
St. Luke's and San Francisco Hospitals and downtown sections extending 
from Eighth to Second streets, furnished a large volume of the patients. 

San Francisco Hospital — While the majority of the new patients 
attending the hospital's Tuberculosis and Prenatal Clinics came from the 
nearby locality, it is of interest that a considerable number came from dis- 
tant sections of the city, notably Telegraph Hill, where the Neighborhood 
Association maintains one of the Board of Health Chest Clinics and a 
Prenatal Clinic, and from the neighborhood of Mount Zion Hospital, 
which also maintains a Chest Clinic and a Prenatal Clinic, and from the 
vicinity of St. Luke's, which has no tuberculosis clinic facilities or special 
service for pregnant women. 

Children's Hospital — As the chief center for care of sick children, the 
dispensary draws patients from nearly every section of the city, with an 
increased number coming from the Potrero and Sunset districts, and the 
largest number from the immediate vicinity of the hospital and from the 
Telegraph Hill district. 

Homeopathic Clinic — The new attendance at the Homeopathic Clinic, 
thirty-nine in all, was too small to be of value. It is significant, however, 
that one-third of the total new patients admitted during the two months 
came from the Deaconess Home, which adjoins the dispensary and with 
which it is loosely affiliated. 

Lane and Stanford University Hospital — -In addition to a rather gen- 
eral distribution of patients throughout the older sections of the city, the 
dispensary serves definite districts, large numbers of patients coming from 
the sections north of Market street, the district bounded by Eighth, Chan- 
nel, Market, and Second streets, and from the near neighborhood of the 
hospital. 

Mary's Help Hospital — Mary's Help dispensary is furnishing care pri- 
marily to its own district, a maximum number of new cases coming from 
the immediate neighborhood of the hospital. 

Mount Zion Hospital Dispensary — The dispensary maintained at 
Mount Zion also shows a fairly well-defined neighborhood service as, 



r^ ^ ^ 



Si 




CO 

P-< 
< 



102 Hospital and Health Survey 



except for a few scattered patients in other sections of the city, the new 
patients came from the immediate vicinity of the hospital and the section 
bounded by Market, Larkin, Geary, and Fillmore streets. 

Although no study was made of the area served by San Bruno Health 
Center, it was understood that the service is primarily to residents of the 
locality. 

St. Luke's Hospital — The area served by St. Luke's is largely confined 
to the immediate vicinity of the hospital, only occasional patients coming 
from other districts. This is particularly of interest in view of the hospi- 
tal's endeavor to establish the dispensary as a health center for its neigh- 
borhood. No study was made of the area served by the Canon Kip 
Memorial Clinic. 

San Francisco Polyclinic — Based upon the addresses of the two 
months, the Polyclinic's new patients came from the scattered sections all 
over the city, with a concentration of cases from its own neighborhood and 
that of Telegraph Hill. 

Telegraph Hill Dispensary — This dispensary, the undertaking of a 
neighborhood settlement, shows the highest percentage of neighborhood ser- 
vice, 96 per cent of the new patients coming from its immediate sur- 
rounding district. 

DISPENSARY PLANTS 

Due to the recent rapid growth in dispensary service and attendance, 
there is throughout the country a general inadequacy of physical facilities 
for dispensary care. 

In San Francisco, as in other large cities, few of the dispensaries are 
suited either in original plant or arrangement of space, to meet the 
demands of modern dispensary operation. 

At Mount Zion the dispensary department is housed in a building of 
comparatively recent construction, planned for the purpose and well- 
equipped, but its operation is handicapped by overcrowding. The Poly- 
clinic building, while planned for dispensary purposes, lacks essentials in 
arrangement of space, convenience of facilities, and needs additional equip- 
ment to facilitate the work. 

The dispensary departments of the University of California and Lane 
and Stanford University Hospitals, notwithstanding much special equip- 
ment and many unusual facilities, are conducted under physical handicaps, 
the latter especially presenting a picture of compromise arrangements, 
insufficient space, and awkward working conditions. 

The quarters at Mary's Help, Children's, and St. Luke's Hospitals 
do not provide essentials as to space and arrangement. Mary's Help 
appears to need additional equipment for special services, the dental facili- 
ties being a striking exception. Children's, while excellent in equipment 
and ingenious in use of space, is conducted in limited and unsuitable quar- 
ters. St. Luke's operates under hampering physical conditions, likewise 



Services for the Sick 



103 



Telegraph Hill, although a resourceful use of space at the latter lessens 
the obvious inadequacies of the original plant. . 

The method of operation in effect in practically all of the dispensaries, 
with from 77 to 100 per cent of the scheduled sessions occurring in a few 
hours of the day, emphasizes the original physical defects. 

From a community service viewpoint, the chief defects of the dispen- 
saries — prolonged waiting and overcrowded clinics — result from this fact. 
It should be stated that in no instance was prolonged waiting for clinic 
treatment regarded by the dispensary workers interviewed as a defect of 
service. A two-hour wait was stated to be common, and was viewed as a 
natural phase of dispensary operation. 

In particular, recognition should be given to the constant difficulties 
which confront the work of the dispensary and medical staffs. Cramped 
quarters, long and crowded clinic sessions, inadequate and inconvenient 
waiting and dressing-room facilities for patients, constitute working condi- 
tions far from ideal. 

Taken as a whole, in view of the growing recognition of the commu- 
nity worth of dispensary services and the continued increase in the dispen- 
sary activities of the city, the physical conditions in the institutions suggest 
that (a) a reorganization of clinic schedules is indicated, (b) a rearrange- 
ment of space is needed, and (c) additional space is highly desirable. 

The limitations under which most of the work is conducted necessi- 
tate compromise on the part of the working and medical staffs. The daily 
impact of large numbers of patients of all types and ages places a tax 
upon dispensary workers even when there is ample space, suitable arrange- 
ments, and specially planned facilities. Judging by the experience of other 
dispensaries, there is a cost of slow dispensary service to both patients and 
workers. Factors related to working environment which are receiving 
increasing attention in the business world, appear equally important in 
undertakings such as dispensaries, in which the business is to serve human 
beings and in which the volume of work indicates a steady increase in 
demand. 

DISPENSARY FINANCES 



Insufficient information was furnished to permit of any analysis of 
dispensary finances. It is not known how much is expended for dispen- 
sary care in San Francisco. The accounting systems at most of the larger 
hospitals yield such facts, but it appears that the accounts of the smaller 
hospitals and of organizations other than hospitals maintaining dispen- 
saries as one of their activities, are not so kept as to furnish these data. 

It is obvious that the cost of dispensary care should be analyzed with 
the same detail as the cost of service in hospitals, i. e., by economic and 
medical classification of patients. 

The importance of the preventive functions of dispensaries, as well as 
their services to the sick, requires more careful record of facts and analysis 



104 Hospital and Health Survey 



of administrative and medical services than has been undertaken anywhere 
in San Francisco. 

The opinions of the medical profession in regard to dispensary care 
is expressed in the following quotations from letters of physicians reply- 
ing to inquiry regarding (a) the need for more dispensary service of any 
kind, and (b) the adequacy of the present precautions taken through social 
service or otherwise to prevent the abuse by patients of free medical care : 

''There is a lack of co-operation between the various departments of the 
existing dispensaries. Reports are rarely rendered to the physicians sending 
patients to the dispensaries for diagnosis." 

'There is need for more efficient collaboration between the medical services 
within the clinics in teaching and research, in order that there be more efficient 
prevention of disease and treatment of the sick." 

"The restriction imposed by the very limited 'free bed' accounts hamper the 
care of the sick. The sums available for free care are used to supply medicines, 
X-rays, Wassermanns, etc., leaving almost nothing for free bed care." 

'We need more support to improve the quality as well as the quantity of 
service given. We lack sufficient doctors and are short of nurses and social 
wrokers." 

"Most semi-private dispensaries are lacking in funds to provide special exam- 
inations — such as X-ray- — and lack the needed space for hospital care of dispen- 
sary patients." 

"Clinic patients, as in other parts of the country, do not receive careful 
enough consideration of their condition and complaints — i. e., incomplete histories, 
inadequate physical examinations, incomplete laboratory investigation, and ill- 
considered treatment. The difficulty lies in the custom of trying to handle all 
who come, but also in the training and individual standards of the profession." 

"Ambulatory clinic patients frequently require hospital attention and are 
unable to get it on account of lack of necessary funds. I refer to such cases as 
require but a few days of bed care and to such as do not wish to go, or should 
not go, to the San Francisco Hospital." 

"It is too easy to secure appointments on our out-patient clinic staffs, and 
the work of the men in the clinics is not adequately systematized." 

The medical opinion was emphatic regarding the inadequacy of the 
precautions taken to prevent dispensary abuse, there being almost unani- 
mous opinion to the effect that due precautions are not taken. To quote : 

"I believe that at our own clinic fully one-half can afford moderate hospital 
and doctor fees." 

"I personally feel if the clinics would look up the financial status of more 
of their patients, there would be adequate room, and more time and attention 
could be paid to deserving poor." 

"Many clinic patients can well afford private care." 

"Social workers of free clinics seldom investigate financial status of appli- 
cants, with exception of Children's Hospital." 

"I do not believe that adequate precautions are taken, but it is better to serve 
the unworthy than to neglect one worthy." 

"Either precautions are not taken or else the free clinics desire such a large 



Services for the Sick 105 



turn-over of patients (as for student instruction) that all comers are received, 
without bothering about their financial status." 

"Not enough investigation is made of the income and finances of a patient 
applying for free treatment. People who can well afford to pay a private physi- 
cian are receiving free medical and surgical care/ 



}> 



The opinions of those connected with the non-medical social agencies 
emphasize the need for increased financial support for dispensary depart- 
ments. The belief appears to be general that adequate social service, steno- 
graphic and clerical staffs are especially needed to provide the most desira- 
ble quality of dispensary care. 



Chapter 3 

HOSPITAL SOCIAL SERVICE 

Hospital social service in San Francisco is provided by six of the ten 
hospitals. Of the two public institutions, one, the University of California 
Hospital, has a social service department ; that at the San Francisco Hos- 
pital has other functions and is not here included in the social service 
resources of the city. Of the privately controlled institutions, five have 
established departments — Children's, Lane and Stanford University, Mary's 
Help, Mount Zion, and St. Luke's Hospitals. 

• Combined, these six departments have a total of twelve workers, 
including social workers and nurses, two of them having one worker, 
Mary's Help and St. Luke's Hospitals, the majority of the workers being 
attached to the departments of the two university hospitals. 

As in many other cities, social service has developed largely through 
the initiative and stimulus of non-medical and non-hospital groups. In 
San Francisco the establishment of the work and its continuation and 
growth have been chiefly due to groups of women who, prior to the joint 
financing provided by the Community Chest, raised the funds needed and 
who continue to supply much volunteer service to the work of many of 
the departments. 

The functions of the social service departments in the six hospitals 
range from the mere giving of relief and investigating patients' ability to 
pay for hospital or medical care, to the most modern type of medical social 
service. 

In the opinion of both physicians and social workers, there is an 
undue amount of time and attention now devoted to the question of finan- 
cial investigation, clerical work, and the handling of out-patient depart- 
ments, with the result that social assistance which should be available for 
attending staffs is much reduced. 

A study of the reports of the departments and contact with those in 



106 Hospital and Health Survey 



the work emphasizes the disproportionate amount of attention which is 
directed to work which is not properly medical social work. 

As social service is a new element in the hospital family, its position 
and functions are not as yet universally recognized, with the result that in 
many communities the work is still undeveloped as either an integral' part 
of hospital care, or as a general community resource for handling commu- 
nity medico-social problems. 

The primary function of medical social service— assisting in the medi- 
cal treatment of the sick — is largely obscured in San Francisco by the fact 
that the work of the social service departments includes the executive con- 
trol of dispensary departments, and by the extent to which departmental 
attention is focused on financial investigation, determining the ability of 
patients to pay, clerical detail, etc. 

Social service does not factor in medical care for the purpose of find- 
ing out what patients can pay, nor for the sake of helping to run out- 
patient departments. Its special work is to furnish information and assist- 
ance to physicians for their guidance in the treatment of their patients. 
In supplying these it collects, evaluates and interprets facts regarding 
environmental, occupational, and family conditions, including the ability to 
finance sickness without worry and anxiety. 

There is considerable difference of opinion among hospital social ser- 
vice workers regarding the extent to which social service departments 
should collect financial data, but it is increasingly recognized as part of the 
administrative detail properly belonging to admitting offices, and not a 
function of a department assisting in medical care. 

For an institution wishing to protect its attending staff and contribut- 
ing public from imposition by persons who are financially able to meet the 
cost of their care, the necessary investigations should be made, but it is 
not necessary to use a medical social worker to obtain these facts. The. 
work appears to fall to social service because, as hospitals are organized 
today, no others within the hospital organization possess the requisite 
knowledge regarding standards of living, family budgets, dependency, etc., 
necessary to make just decisions. 

The physical quarters provided for the departments in the six hospitals 
are generally inadequate and furnish no, or only limited, opportunity for 
interviewing patients in privacy, a facility regarded as essential to suc- 
cessful social work. 

The opinions of physicians and those connected with the non-medical 
voluntary agencies reflect the fact that more workers are needed in the 
hospital social service field in San Francisco. To quote opinions on the 
subject: 

"We need competent and trained paid social workers who understand family 
problems, to follow up patients into their homes and see that the medical treat- 
ment they need is carried out." 

"I feel that case study is not done well enough. Under the head of medical 



Services for the Sick 107 



social service, the work is essentially economic decisions rather than medical 
social service. " 

"There is a need for better organization, less financial investigation and 
increased workers. These would permit concentration on medical problems, 
follow-up, etc." 

"There is excellent co-operation between the medical and non-medical social 
agencies, but the limitations imposed on the social service departments make it 
almost impossible at times to get patients admitted to the right institution. It is 
undeniable that the work of the hospital's social service departments are ham- 
pered by the lack of facilities which should be available. I refer to home nursin 
service and facilities for convalescents and chronics." 



g 



"If the social service workers could devote their time to medical follow-up 
and similar social service work, instead of keeping accounts and managing clinics, 
we could do better work for a greater number of patients. They do all they can 
and are devoted, but their work is organized poorly." 

The extent to which social service is used by the various medical ser- 
vices of the several hospitals is not shown in the department reports. 
There appears to be, however, only small reference of ward cases by 
members of the attending staffs. Except for the few services which have 
their own social workers, most of the ward patients coming in contact 
with social service appear either to have been previously known to the 
departments, or to have been discovered through personal visits of workers 
to wards — indicating the need for a more clear-cut hospital and medical 
staff policy regarding the utilization of social service. 

The need for a more active reference of ward patients was clearly 
demonstrated during the visits to recently discharged patients. Case after 
case presented problems which could have been met if the social service 
resources of the hospitals had been utilized, but which only became known 
through the accident of the Survey. To cite some of the situations found : 

Case No. 19 — One hospital, which has the proper machinery for referring its 
ward patients to its dispensary and social service departments, appeared to 
have overlooked the question of follow-up and social service supervision in the 
case of a mother who had been a free patient in the wards for almost a month 
for a rectal operation. The father is a junk dealer and the family poor. There 
are rive children, the oldest 15 and the youngest a baby of three months. When 
visited three weeks after leaving the hospital, the patient was miserable and was 
doing the housework for the entire family. She had received no instruction when 
discharged from the hospital, the baby was sickly, but the patient was not well 
enough to carry it to the dispensary. The case presented a picture of a sick 
mother returning to a home of poverty to take up the burden of caring for a 
family of seven — most of them young children. Lacking instruction as to her 
further care and unable to adjust home conditions so she could go to the dis- 
pensary, she was helpless and despondent. She needed the guidance and friendly 
interest of a visitor in her home (preferably one who had seen her in the hos- 
pital and had established friendly relationships), if not financial aid to tide her 
over the period of her home convalescence. 

Case No. 20 — This is a case of a family in which both the man and his wife 
were ill. He had been in the hospital for five days with acute tonsillitis and 
peritonsilar abscess, his wife having been previously in the hospital for a week 
with a throat condition, had returned home the day her husband entered the 
institution. When visited his physical condition was poor. He was miserable 
and in need of dispensary supervision, but as he worked from 7 in the morning 



108 Hospital and Health Survey 



to 7 at night, there was no clinic which he could attend in his free time. A 
washer in a garage, he was worried about his job, as he had been threatened 
with discharge because of his absence from work while sick, although his 
employer had decided to give him less money and keep him. This family is 
able to meet its ordinary financial responsibilities. The husband makes $4.25 a 
day, paid $21 for his wife's stay in the hospital and $15 for his own care.- This 
evidently took most of the family savings, for when visited they were having 
a very hard time and did not have a cent in the house, although $17 was owing 
them. The case was reported to the social service department of the hospital, 
which took up the matter with the man's employer, who readily made arrange- 
ments for the patient to have all the time necessary to attend the dispensary. It 
was evident that all they needed was a little assistance and friendly interest to 
right their situation, for they disclaimed any need for financial relief as long as 
the husband was working. 

Case No. 21 — The patient, a middle-aged woman, had been in the hospital two 
days for treatment for cancer, paying $2.50 a day. She had been previously in 
the hospital for nineteen days for similar treatment in the preceding month, her 
hospital bill at that time amounting to $50. Her condition is so serious that she 
will soon be in need of care in an institution for the chronically sick, for she 
cannot be cared for at home, as the family consists of her husband, two grown 
sons and a child of nine. The father is the sole w T age-earner, making $3.25 a 
day. The two sons — one a fireman and the other a machinist — do not work because 
"one is nervous and the other has a hernia. " This case presents problems calling 
for very special assistance. Provisions will soon have to be made for the patient, 
as her condition is progressively serious and she could not receive the treatments 
she needs at the hospital of the Relief Home. In addition, a study should be 
made of the family with special reference to the claimed disability of the two 
sons, and of their responsibility regarding payment for their mother's medical 
and hospital care. 

Some of the families visited presented health and social problems 
requiring close co-operation between medical and non-medical agencies. 
That this co-operation does not always exist appears to be due to inade- 
quate provision for social service, as reflected in the following cases: 

Case No. 22 — The patient was a baby of 21 months, a part-pay patient in the 
hospital one day for tonsillectomy. The family, deserted by the father and sup- 
ported mainly by State and private funds, consisted of three children, the oldest 
under the supervision of the clinic for a misplaced hip due to bone trouble, the 
patient, an abnormal baby who, though nearly two years old, did not yet walk, 
and a five-months-old baby, apparently well. A feeble-minded uncle comes daily 
to assist with the housework, an aunt also occasionally assisting. The patient 
had a skin condition that needed immediate medical attention, and was referred to 
the hospital's clinic. There had been no follow-up from the hospital, which has 
but one social worker. 

Case No. 23 — A patient, a man of 31, a lumberman by trade, had been ill a 
long time, his present stay in the hospital lasting three months. Both of his 
legs had been broken above the knee tw 7 o years previously and he has not been 
able to get around since. The bones were not properly set at the time of the 
fracture and the patient was in bed thirteen months. His present hospital treat- 
ment had consisted of bone grafting. He was receiving excellent care at home, 
was being visited by his surgeon or assistant, and was still in a body cast. His 
wife was intelligent and everything for his comfort and improvement was being 
done. There was, however, a question as to> the favorable outcome of the opera- 
tion. This type of case, bedridden for so long a period, is the type for which 
occupational therapy has proved highly beneficial. The interest and assistance 
of the hospital and of his doctor are evident, the hospital making a charge of 
$1 a day and waiving or materially reducing extra charges. The beneficial 
results of occupational work as a factor in returning the long-term patient to 



Services for the Sick 109 

usefulness suggest the advisability of such treatment. The question of the 
favorable outcome of the present treatment also suggests the advisability of a 
definite occupational program, with reference to possible vocational re-education. 
The hospital has no social service department, so close working relationship with 
the more specialized social groups is not established. 

The three fundamental principles as to organization, function and 
policy of social service departments advocated by the National Committee 
on Hospital Social Service of the American Hospital Association, in its 
report 8 of a survey of social service in Canada and the United States, 
are: 

1. That the department be organized as a department of the hospital 
with its head worker responsible to the superintendent or chief executive 
officer of the institution, and that it have its own budget. 

2. That there be a social service advisory committee appointed by the 
governing board which should meet regularly and which should include 
representation of the board and the staff, social workers in the community, 
non-professional men and women, the superintendent of the institution and 
the head worker of the department. 

3. That the department carry on educational work for such groups 
as social workers, student nurses, medical students, etc. 

As to the first, the head workers of the departments are responsible 
to the superintendent, but few of the departments operate on a budget 
basis. 

As to the second, none of the hospitals have advisory committees con- 
stituted as outlined, although many of the individual workers feel the need 
for closer contact with staffs, outside social organizations and other insti- 
tutions, and would welcome such committee guidance. It has been the 
experience in other localities that co-ordinating committees organized along 
the broad lines suggested anticipate misunderstandings, reduce duplica- 
tions and familiarize staffs and boards with community problems as well 
as with questions relating to hospital care and service. 

As to the third fundamental, the small extent to which the educational 
opportunities of the departments are being utilized, suggests that the 
developments in this regard do not approximate those in other medical and 
nursing educational centers. The effective utilization of some of the 
departments is hampered by lack of space and insufficient staffs. 

Only a few student nurses and some of the medical students attend- 
ing Stanford Medical School have the opportunity to learn at first hand, 
tinder trained workers, the relationship between medical and social prob- 
lems. Case conferences as conducted for Harvard medical students with 
social workers or members of the attending staff of the Massachusetts 
General and Children's Hospitals ; visits made by medical students with 
workers to the homes of patients, as at the University of Indiana; lectures 
to medical students by the head of the social service department, as at 
Washington University and the University of Minnesota, are instances 



8 Bulletins Nos. 23 and 24, American Hospital Association. 



110 Hospital and Health Survey 



of the opportunities provided at other universities. The social service 
experience of the Stanford students is an excellent beginning, but it is 
apparent that of the hundreds of medical and dental students and student 
nurses coming within the influence of the two leading universities of the 
Pacific Coast, few receive planned experience in a subject so vital to their 
professional equipment. 

Social Service at the San Francisco Hospital 

Social service at the San Francisco Hospital is essentially an adminis- 
trative matter — the determination of the civil and economic right of 
patients to admission to the hospital. 

Although there is an increasing effort to co-operate with the private 
social and medical agencies, the organization, number of workers and the 
functions of the department are not planned for medical social service 
work. 

In consequence the hospital care is frequently incomplete and pre- 
ventable hardships and unnecessary misery are permitted to exist. 

The need for an adequate social service department at this hospital, 
conceived as an adjunct of medical care, was the striking fact brought to 
light through the visits to fifty discharged patients during the convalescent 
study. To cite but a few of the cases for which social service was indi- 
cated, we can quote the following reports made by the investigators for 
the Survey : 

Case No. 24 — A young father and mother, with a baby of 18 months and one 
ten days old, were found struggling against discouraging odds. The financial con- 
ditions were serious, the family living in three very poor rooms and the father 
out of work. He had been operated upon in the hospital for mastoiditis and was 
still returning for dressings. The mother was endeavoring to do all the house- 
work, although recently back from the hospital herself and in need of post-natal 
supervision. The family was reported immediately to a relief agency for finan- 
cial assistance, the man was referred for suitable employment to the workers 
then making a study of handicapped persons, and the mother referred for dis- 
pensary care — all services which are commonly handled by a hospital's social 
service department. 

Case No. 25 — A young man in the hospital for a month for an operation for 
the removal of a foreign body in the abdomen which had been followed by 
abdominal fistula, was in need of special assistance to find suitable employment. 
He had had nine operations and much sickness, had become deaf following an 
attack of measles, and had had empyema following influenza. A few years ago 
he had been operated upon for appendicitis, following which he developed a 
hernia, for the correction of which he had undergone two operations, the last 
for the removal of some bismuth which had become imbedded in the intestines. 
When visited he still had a slight discharge from an abdominal wound and he 
was going to the hospital every day for dressings. Although he was improving 
steadily in his general health, was most appreciative of all the work which had 
been done for him, and eager for employment, he was still weak and was in 
need of occupational therapy and of special assistance to find suitable work, 
handicapped as he was by deafness and the debilitating effects of prolonged 
sickness. 

Case No. 26 — Particularly pathetic was the case of a single man of 68 with 
pernicious anemia, who was in the hospital over a month. He was without 



Services for the Sick 111 



money, drifting from lodging house to lodging house, wandering around office 
buildings looking for work. He was referred by the visitor for the Survey to 
the workers conducting the study of the handicapped, for possible occupational 
placement, or if his condition prevented his working, for admission to the Relief 
Home. 

Case No. 27 — The home environment and facilities for the after care of a 
little boy who had a tonsillectomy operation were ill suited to his needs. The 
family, in addition to the patient, consists of the father, who is a printer and is 
employed all day; the mother, employed from 9 a. m. until 2 p. m., and a child 
of 10. The children are left in charge of a cousin of 11 years of age and an 
uncle who comes in for lunch. The family takes one quart of milk a day, the 
patient getting a cup of milk or cocoa daily. He was in poor physical condition. 
His operation, and also dental work at the Dental School, had been arranged for 
by the school nurse. 

Case No. 28 — A young man was visited who had been unable to work for 
nine months because of an inflammatory bone condition of the jaw, following the 
extraction of several teeth. Because of his inability to support his family, his 
home had been broken up, the patient living with his parents and his wife and 
young baby living with her parents. He had been in 'the hospital for two 
months, had gained thirty-two pounds, was able to eat only soft foods, and was 
going to the hospital daily for dressings. He was in need of special assistance 
to find the type of work suited to his condition and was referred to those studying 
the problem of the handicapped worker. 

Many additional cases presented both major and minor social and 
health problems (among them cases No. 9, No. 11, and No. 16, given in 
Chapter 2), requiring expert social diagnosis and treatment of matters of 
home environment, employment, poverty, hygiene, and a close working 
relationship with the attending staff of the hospital and with the various 
relief and social agencies of the city. 

In view of the fact that there is considerable opinion in San Francisco 
to the effect that a central social service agency or the social service 
departments of the two university hospitals, could meet the medical social 
service needs of the San Francisco Hospital, it should be borne in mind 
that the critical time for a patient as an individual being returned to use- 
fulness, is prior to or at the time of discharge. It should certainly be the 
aim of the city to provide as completely for the indigent sick by means 
of all the known supplementary aids to medical care, as private medical 
practice provides for the private patient. In the latter the physician gives 
the questions of after-care, convalescence, suitability of occupation, etc., 
his personal attention. In hospital ward practice the medical social worker 
as his agent acting on his orders, collects and interprets facts related to 
similar questions regarding ward patients, upon which subsequent medical 
care can be based. 

The admirable manner in which the problems of financial investigation 
and medical social service work are handled at the Buffalo' General Hos- 
pital, 9 a municipal institution, suggests the advisability of a study by the 
Board of Health of the methods at this hospital, with a view to applying 
somewhat similar principles and methods at the San Francisco Hospital. 

9 (a) Bulletin Buffalo City Hospital — Routine Admission of Patients and Financial 
Investigation Incident Thereto, 1922. 

(b) Report of an investigation of the Department of Hospital and Dispensaries, 
Buffalo, New York. Haven Emerson, 1922. 



112 Hospitai, and Health Survey 



Summary 

Much can be said in praise of the accomplishments of the individual 
hospital social workers, handicapped as they are by insufficient recognition 
of medical social service and inadequate provisions for effective work. 

It is evident that, in the field of medical social service throughout the 
city, there is much to be done. In particular, an increase of workers is 
needed so that the departments will be able to do more effective work. 
The functions of hospital social service must be more clearly understood, 
primarily by hospital boards and executives. 

For these purposes there will be required (a) increased funds, and 
(b) the establishment of generally accepted standards for the work, spe- 
cifically relating* to the following : 

Functions of hospitals social service. 

Organization of social service departments. 

Organization and responsibility of social service committees. 

Educational activities. 

Contact with non-medical agencies. 

Use of volunteer workers, etc. 

The responsibility for the establishment of standards should prefer- 
ably be the particular work of a committee of the proposed Hospital 
Council, providing for representation of the social service departments 
through their respective head-workers, and of social service committees of 
managing boards, the San Francisco Medical Society, non-medical chari- 
ties, public health nurse organizations, Department of Public . Health, etc. 

Chapter 4 

VISITING NURSE SERVICE 

"The public health nurse is any graduate nurse who serves the health of the 
community, with an eye to the social as well as the medical aspects of her func- 
tion, by giving bedside care, by teaching and demonstration, by guarding against 
the spread of infections, insanitary practice, etc." 10 

The nursing service provided by the various organizations of San 
Francisco employing public health nurses for visiting in homes may be 
classified in four main groups : 

(a) Bedside care for general sickness accompanied by health educa- 
tion, commonly called visiting nursing. 

(b) Bedside care for maternity patients, accompanied by special in- 
struction, such as furnished by the Stanford Clinics Auxiliary and San 
Francisco Maternity and the University of California Hospital, for mater- 
nity patients delivered at home. 

10 Nursing- and Nursing- Education in the United States. Report of the Committee 
for the Study of Nursing Education, 1923. 



Services for the Sick 113 

(c) Social follow-up and health instruction of discharged hospital 
and of dispensary patients, with occasional bedside care, as supplied by 
the nurses constituting the staffs of the Children's and Mount Zion Hospi- 
tals Social Service Departments. 

(d) Follow-up, education, supervision for special groups, etc., with 
no bedside care, as furnished by nurses attached to hospital social service 
departments, school, tuberculosis and nutrition nurses, etc., attached to the 
Department of Public Health, nurses employed by health or social organi- 
zations, such as the Children's Health Center, Junior League, etc., and 
those engaged in industrial nursing. 

The organizations maintaining the foreg'oing public health nursing 

services, together with the extent and character of the service furnished, 

are: 

Number of 
Nurses 

(a) Bedside Care for General Sickness Groups — 

Metropolitan Life Insurance Company 4 

San Francisco Neighborhood Association 3 7 

(b) Bedside Care for Maternity Patients — 

Stanford Clinic's Auxiliary and San Francisco Maternity 2 2 

University of California Hospital Occasional 

student 
nurses 

(c) Social Follow-up, Instruction and Occasional Bedside Care — 

Children's Hospital 2 

Mount Zion Hospital 2 

Schmidt Lithographers . . '. 1 5 

(d) Follow-up, Instruction, etc., with No Bedside Care — 

Private Organizations 

Associated Charities 3 

Children's Health Center ' . . 1 

Junior League 1 

Little Children's Aid 1 

Mary's Help Hospital 1 

Presbyterian Mission 1 

St. Luke's Hospital 1 

St. Mary's Hospital 1 

Stanford Clinic's Auxiliary and San Francisco Maternity 4 14 

Public Organizations 

University of California Hospital 2 

Department of Public Health — 

Child Welfare 4 

Juvenile Court 2 

Nutrition Workers 3 

School Nurses 21 

Social Service Department San Francisco Hospital 3 

Social Hygiene 1 

Tuberculosis Flome Visitors '." 9 45 



114 Hospital and Health Survey 



Industrial Organizations 

American Can Company 2 

Bemis Hag" Company 1 

"Bollman Tobacco Company 1 

California Candy Factory Y 

California Packing Company , 2 

Kmporium 1 

Male's Department Store 1 

National Carbon Company 1 

National Paper Products Company 1 

Western Sugar Refinery 1 

Western Union Telegraph Company 1 13 

From the point of view of financial support, these organizations fall 
under one of three groups — those supported by public funds, those deriving 
their support from charitable donations and fees of patients, and those 
maintained as business enterprises. The following table presents the extent 
of the public health nursing service provided by each group : 

Financial Support of Public Health Nursing 

Number of Nurses Maintained 

Type of Nursing By Public By Private By Business 

Service Furnished Total Funds Charity Organizations 

(a) Nursing Care and Instruc- 

tion 7 (8%) . . 3 4 

(b) Nursing Care and Instruc- Occasional 

tion for Maternity Patients 2 (2%) student 2 

nurses 

(c) Follow-up Home Visits, In- 

struction, etc., and Occa- 
sional Nursing Care 5 (6%) .. 4 1 

(d) Follow-up Home Visits, 

Instruction for Special 
Groups, with No Nursing 
Care 72(84%) 46 13 13 



Total 86(100%) 46 (53%) 22(26%) 18(21%) 

As shown in the foregoing table, 84 per cent of the nurses visiting in 
homes do no bedside nursing, 6 per cent furnish such care only occasion- 
ally, 2 per cent nurse maternity patients (exclusive of the occasional stu- 
dent nurses at the University of California caring for maternity patients 
delivered at home, totaling less than fifty cases yearly), and but 8 per cent 
devote practically all their time to bedside care. 

It is apparent, then, that what is generally spoken of as visiting nurs- 
ing — sometimes called district nursing — is provided in San Francisco by 
the three nurses attached to the San Francisco Neighborhood Association 
and by the four nurses of the Metropolitan Life Insurance Company. 

Public health nursing, as represented in the instructive and special 
follow-up nursing services of the Department of Public Health, is well 



Services for the Sick 115 

developed. The same is true regarding other phases of health education 
work provided by the nursing staffs of various private organizations spe- 
cializing in health and public welfare activities. 

Visiting nurse care of the sick in their homes is obviously so unde- 
veloped as to be practically non-existent. 

That a city of 540,000 population has available for visiting nurse care 
in homes but seven nurses, four of whom are only available for the policy- 
holders of an insurance company, indicates a meager development of one 
of the outstanding services for modern care of the sick. This is particu- 
larly the case, in view of the fact that the visiting nurse is today ranked 
as one of the most valuable elements in health work, because of the unique 
and intimate place she occupies as the family health educator. 

San Francisco's lack of development of this service is unusual. No 
other city of its size in the country lacks this service. The number of 
public health nurses, and of these the number giving bedside care in the 
eight cities of the United States ranging from 400,000 to 600,000 popula- 
tion, is as follows : 

Number of Public 
Population Total Number of Health Nurses 

1920 Census Public Health Giving General 

Nurses * Bedside Care 

Pittsburgh 588,343 112 78 

Los Angeles 576,673 64 40 

Buffalo 506,775 83 46 

San Francisco 506,676 40 3 

Milwaukee 457,147 90 26 

Washington 437,571 54 26 

Newark 414,524 80 13 

Cincinnati 401,247 55 16 

*Exclusive of industrial nurses and those employed by social service departments. 

With so limited a visiting nurse service, it was natural that many of 
the cases visited showed a need for nurse follow-up to see that doctors' 
orders were being carried out, provide instruction as to diet, hygiene, 
health promotion, etc. A few of the patients needing such nursing care 
may be cited : 

Case No. 29 — The young mother of four children, a colored woman, was a 
free patient for six weeks in one of the hospitals, with diabetic gangrene, which 
necessitated the amputation of a first finger. When visited she was going to 
the dispensary once a week for dressings and was following the diet instruction 
given by the doctor at the hospital. The patient returned home to do the work 
for her family, the youngest a baby only a few months old. The home was 
crowded and untidy, the older children trying to help with the housework. This 
patient was in urgent need of the service, supervision and stimulation of a visit- 
ing nurse, to instruct and assist her in preparing her diet and to assure the con- 
tinuance of her dietary treatment. 

Case No. 30 — A patient was in one of the hospitals for five weeks following 
an operation for uterine tumor. When in the hospital the incision broke open 
eight days after the operation, necessitating a second operation under anesthesia. 
As she was considerably nauseated after the second operation, the doctor could 
not be certain that the inner stitches held. On discharge the patient was told a 
possible hernia might develop in the wound, if at all, within the next few 



116 



Hospital and Health Survey 



months. No attempt was made by the hospital to keep in touch with her, and 
no instruction was given as to the proper course for her to follow during the 
period while waiting for the possible hernia to develop. 

Case No. 31 — Visiting nurse care would have met many of the needs of a 
child of 3 who was sent home after a ten days* stay in the hospital for ,tonsil- 
litis, with a bad cough and running nose, no instructions being given 'her mother 
regarding any home care. Other children in the hospital had measles, and ten 
days after the patient came home she also developed measles. The child had a 
persistently poor appetite and a succession of colds, but the mother had had no 
instruction regarding upbuilding care or the special supervision needed. 

Case No. 32 — A boy of 4 was for four days in one of the hospitals which 
has a social service department — diagnosis: tonsillitis and otitis media. The 
parents paid 50 cents a day for his care. The visitor for the Survey states: 
"If a visiting nurse had been sent to this home for follow-up care the inade- 
quacy of this family to follow the instruction given would have been known." 
The family was in great need. They had been in California only a few months, 
and the father, a shoemaker by trade, had only been able to get work for a 
day or two a week since his arrival. There were three children, the oldest 4 
and the youngest 1^2 years old. The mother, five months pregnant, did not 
know where to go for care. She was referred by the visitor for the Survey to 
an agency for financial aid to tide them over their period of trouble and to a 
prenatal clinic. Even the $2 charged by the hospital must have been a tax on 
a family so handicapped by unemployment and lack of money. 

It is judged that a visiting nurse service, in view of the small amount 
of dependency in the city, would be at least two-thirds self-supporting. 
The experience of other cities in this respect, presented in an authori- 
tative report 11 of public health nursing in the United States, is of interest: 

Proportion of Patients Paying in Full, in Part or Not At All, for Visits from 
Thirteen Privately Supported Visiting Nurse Associations During 

the Year Preceding This Study* 

Number and Per Cent of ^Per Cent of Patients Paying for Visits-^ 

Type of Patients Paying in Paying in 

Organization Visited Free Total Full Part 

Urban: 

1 100.0 

2 100.0 

3 100.0 

4 100.0 

5 42.6 57.4 36.3 21.1 

6 39.5 60.5 45.2 15.3 

7 37.6 62.4 57.3 5.1 

8 31.0 69.0 46.9 22.1 

9 27.2 72.8 43.9 28.9 

10 25.0 75.0 10.0 65.0 

Rural: 

11 2.0 98.0 94.4 3.6 

12 35.6 64.4 ** ** 

13 99.4 0.6 0.6 

*These figures are based on reports submitted by these organizations. Visits made 
for the Metropolitan Life Insurance Company were counted as full pay visits. These 
were included in four urban societies' reports. 

♦♦Distinction between those paying in full and in part was not made in report given 
us by this organization. 



li Nursing and Nursing Education in the United States. Report of the Committee 
for the Study of Nursing Education, 1923. 



Services for the Sick 117 



Certain of the cases visited indicate that there is at present a demand 
for visiting nurse care among patients who pay in whole or in part for 
their hospital care, illustrated in the following: 

Case No. 33 — A woman of 41, in the hospital for a month, had an opera- 
tion for cancer of the breast so extensive and severe that she had to have a 
blood transfusion. Three weeks after discharge from the hospital, when she was 
visited, she was sleeping badly, her arm was swollen and painful and her appe- 
tite poor. She was attending the hospital's dispensary for dressings and physio- 
therapy treatments three times a week. When she came home from the hospital 
she was so ill she had been unable to go to the clinic and secured the Metro- 
politan nurse who came in once to do her dressing. The picture is one of a 
patient returning home sick and miserable and in need of some nursing care. 
As she had paid $189.95 for her hospital care, she would have been able to pay 
for convalescent care in an institution or visiting nurse service at home had 
either of these been available. 

Case No. 34 — Another patient expressing a desire for home nursing care, was 
a woman who had been in the hospital for a little over two weeks for an opera- 
tion for a breast tumor. Although all the nursing care needed was assistance 
in taking her bath, getting dressed, combing her hair, etc., as the patient's sister 
could do everything else for her, she was employing a nurse for twelve hours 
daily. Her needs could have been admirably met by the services of a visiting 
nurse for a few hours, The patient expressed the opinion that there was a need 
in San Francisco for visiting nurse service for which payment could be made 
on the basis of the time used. 

Case No. 35 — This case is also of interest as indicating a recognition on the 
part of a full-pay patient that the services of a visiting nurse would have met 
all his nursing needs after his return home from the hospital. This patient, in 
the hospital for five weeks for an operation, was discharged to his private physi- 
cian. His dressing was being changed daily, and he wished there was a visiting 
nurse service in the city, so he would not have to get up and go to the doctor's 
office for dressings. 

Case No. 36 — A young woman, in the hospital for fifteen days for an abdomi- 
nal operation, received instructions before discharge regarding subsequent care, 
but she needed visiting nurse instruction at home to teach her how to carry 
them out, a service which was not supplied, although many of this institution's 
discharged patients receive instruction at home. This patient is in the part-pay 
group, paying at the rate of $4 a day at the hospital, having made arrangement 
to pay $15 a month until her bill was paid. 

San Francisco needs a visiting nurse association to spread the kind 
of service that is being given by the San Francisco Neighborhood Associa- 
tion on Telegraph Hill to other parts of the community. Provision should 
be made for visiting nurse service so that bedside nursing can be had on 
call and at cost by all people who, under medical direction, wish to have it. 

The combined opinion of groups concerned with health and sickness 
problems of the individual and of the community as a whole, is in agree- 
ment that this is an essential service which should be provided. The ques- 
tion has received considerable attention, and a representative committee has 
collected information and drawn up tentative plans for establishing a visit- 
ing nurse association. 

It is assumed that such a service will be available for all economic 
groups in the population, and that the practice of withholding all visits, 
unless there is a doctor in attendance on the case, will be adhered to. 



118 Hospital and Health Survey 



There is ample experience upon which to draw for guidance in deter- 
mining- such details as organization, contact with the medical profession 
and hospitals, administration, districting, affiliation with training schools 
for nursing, etc. 

On general questions, the National Organization for Public Health 
Nursing is equipped to furnish counsel and advice of the most valuable 
character, while the experience of the San Francisco Neighborhood 
Association would afford assistance in adjusting generally accepted 
methods to local conditions. 



Chapter 5 

CONVALESCENT HOMES 

The inadequacies of the present facilities for institutional convalescent 
care in San Francisco are well known to all in contact with health 
and hospital work. As one social worker said, "The situation is one that 
confronts every social and welfare worker in San Francisco." 

The Council of Social Agencies, through a sub-committee studying 
hospital problems in 1923, reports : "There is a need for a special com- 
mittee to investigate the local need for an institution or home for con- 
valescent patients from hospitals, especially the San Francisco Hospital, 
where convalescent patients could find a temporary home at a minimum 
cost while seeking employment instead of being dumped into the cheerless 
cheap lodging-house. " 

The few facilities for the institutional care of convalescing adults 
and children consist of the Bothin Convalescent Home at Manor, Marin 
County, 37 beds ; Drexler Hall at Redwood City, 16 beds ; and the Stanford 
Convalescent Home at Palo Alto, 16 beds. 

The Patient groups received by the three institutions are as follows : 

Bothin Convalescent Home — Receives boys and girls between 5 and 
10 years of age for general convalescent care and for preventive care ; 
and women of all ages — the accommodations for women being limited 
to two beds. It receives both pay and free patients and is not equipped 
to care for bed cases. Changes now being made will provide ten addi- 
tional beds for girls and will make it possible to use all the facilities the 
year round instead of only eight months, as formerly, but make no 
provision for bed care. 

Drexler Hall — Receives girls from 3 to 18 years of age suffering 
from orthopedic conditions. The institution is maintained entirely from 
private sources and limits its service to free patients. It is not equipped 
to care for bed cases. 

Stanford Convalescent Home — Receives boys and girls from 2 to 12 
years of age, including both pay and free patients, and is equipped to 



Services for the Sick 119 



care for a few bed cases. An admirably planned unit nearing completion 
will provide facilities for 20 bed cases, 10 boys and 10 girls. 

In addition to the foregoing, the Ladies' Protective and Relief Asso- 
ciation plans to build a home for aged women within the city limits, 
which will provide 10 or 12 beds for convalescing women patients, other 
than bed cases or mothers with infants or young children. 

With these additional accommodations, there will be available within 
about one year, a total of approximately 110 beds as follows: 

Bed Cases 

Adults — Men 

Women 

Children — Boys 10 

Girls 10 20 

Up Cases 

Adults — Men 

Women 12 to 14 12 to 14 

Children — Boys and Girls 51 

Girls only 26 11 

Total 109 to 111 

The obvious inadequacies of these facilities are apparent, as they 
include no provision for adult male patients, none for bed care for women 
and only minor provision for up-cases, practically none for mothers with 
infants, and but few beds for special patient groups and those only for 
children. 

The opinions of physicians, hospital administrators, and social, workers 
expressed to the Survey, constitute a convincing array of informed opinion 
regarding the inadequacies of the facilities. 

The members of the San Francisco County Medical Society gave 
more attention to the matter than to any of the subjects on which opinion 
was asked, 62 per cent of the replies testifying to the need for increased 
accommodations. The special groups for which it was considered pro- 
vision should be made, according to the number of replies, are : 

General Medical and Surgical ; Mental and Neurological ; Obstetrical 
and Gynecological ; Pediatric ; Orthopedic ; Ear, Nose, and Throat ; Vene- 
real and Genito-Urinary Diseases ; Dental; Eye. 

A high percentage of the hospitals expressed opinions which indicate 
a pressing need for facilities for free and part-pay convalescing hospital 
patients, a few mentioning in particular the need of accommodations for 
men, mothers with children, and boys over 10. 

Other health agencies emphasized the difficulty experienced in obtain- 
ing suitable convalescent care for free and part-pay patients, especially 
men, women, boys over 10, and women with cancer, the last reflecting a 
rather common confusion of chronic and convalescent problems. 

Social service groups co-operating with health agencies were of the 



120 Hospital and Heai/th Survey 



opinion that there is a general need for facilities for all the economic and 
patient groups. 

To quote some of the individual opinions : 

"The greatest medical need in San Francisco is for free convalescent 'Care." 

'The convalescent facilities are limited to adults — children are taken care of." 

"Convalescent bed care is almost entirely lacking and available only for an 
occasional child." 

"Part-pay convalescent care is needed for patients requiring bed care. ,, 

"At the present time there are no adequate facilities for convalescent care 
for adults in San Francisco. The situation in regard to single men needing care 
during convalescence is really distressing. ,, 

"Convalescent bed care is very insufficient, especially for children.'* 

"Free or part-pay convalescent bed care outside of our large hospitals is 
needed for convalescent children." 

The unsuitability of such institutions as the Relief Home for con- 
valescing patients should need no comment. In the opinion of the super- 
intendent of the Home, the morale of the convalescent, particularly the 
younger man or woman, is permanently injured by association with the 
aged almshouse or chronically ill type of patient. 

The problem of meeting the individual needs of convalescing patients 
is one touching a wide range of health and social services. It includes 
private medical practice, hospital and dispensary service, public health 
nursing, medical social service, convalescent institutional care, vacation 
camps, rest-homes, etc. Experience has proved that it is only through the 
intimate co-operation of these services that the most satisfactory results 
are obtained. 

The visits to recently discharged patients indicated that satisfactory 
convalescence from hospital care is not being obtained in many instances 
in San Francisco because (a) co-operation among the various services 
concerned is insufficiently developed, and (b) three important services 
for supplementing hospital care — medical social service, convalescent 
institutional care and visiting nurse care in the homes — are inadequately 
provided for. 

Many of the conditions found to exist among the 160 discharged 
patients visited in their homes, previously described in various chapters of 
this section, reflect in different types of cases the results of the present 
inadequate co-operation between certain of the existing services respon- 
sible for convalescent care. Additional cases , showing the type of case 
for which institutional care was indicated, were as follows : 

Case No. 37 — The patient, a single man of about 50 years of age, was in the 
hospital for a month with heart disease, and when discharged was unable to 
work, without funds, and dependent on friends who were paying his room and 
board. He had drifted in to one of the independent dispensaries, instead of the 
one to which he was referred, and had been referred also to those working on 
the problem of the handicapped. , What the patient needed was care in a well 
equipped convalescent home providing medical supervision and facilities for 
suitable occupational placement. 



Services for the Sick 



121 



Case No. 38 — A mother of 21, in the hospital to be delivered of her first baby, 
had had a very severe labor necessitating extensive surgical repair. On leav- 
ing the doctor told her to take life easy for several weeks, but this was hardly 
possible, as her husband had been out of work for some time, had only had 
employment for three weeks and was away working in the country. When the 
patient was visited, two days after leaving the hospital, she was washing at a 
tub placed on a low chair so as to work with less difficulty. The patient paid 
$35 for her hospital care, but her financial and physical condition indicated that 
she either needed financial relief so that a houseworker could be provided to do 
the heavy work and she could take life easy as directed by the doctor, or she 
needed care in a convalescent institution until she was strong enough to resume 
her normal life. 

Case. No. 39 — A mother of 22 with three children, was in the hospital eighteen 
days for an operation for chronic appendicitis. On her return home the patient 
took care of her two youngest children who required extra watching, and did 
all the housework except that which her husband could help her with after he 
returned from work, her mother taking charge of the oldest child. It was evident 
that this patient would have benefited by a stay in a convalescent institution fol- 
lowing her operation and should not have been permitted to return to arduous 
household worries and labors. The hospital charge of $15 a week was low, 
but high for a family of five supported by one wage-earner making $35 or less 
weekly. 

When convalescent care is not adequately provided for, either at home 
or in special institutions, waste of hospital service results, due to the fact 
that patients are frequently discharged from hospitals before they are able 
to take up the burdens of home and occupation. Avoidable suffering, not 
infrequently relapses, and often a more or less protracted period of weak- 
ness results. With the object of preventing these and similar misfortunes, 
patients are retained in hospitals for the acutely sick longer than would 
be needed if suitable facilities for convalescence were available. This is 
especially true regarding the ward patient, whose home conditions are so 
frequently unfitted to the type of convalescence needed. 

The extent to which long-term patients are held in the hospitals for 
the acutely sick in San Francisco is indicated by the fact that, of the 1805 
patients in the hospitals on June 21, 11 per cent had been in the institu- 
tions from 31 to 60 days, 4 per cent from 61 to 89 days, and over 9 
per cent for 90 days or longer (shown in Chapter 6 of this section), 
indicating a total of 442 patients in the hospitals for one month or more. 
As many of those hospitalized for three months or longer were obviously 
chronic cases, it is assumed that the 15 per cent in the hospitals from 
31 to 89 days — 273 patients — represents the convalescing group on this 
one day. 

The experience of the large Eastern cities, where the question of con- 
valescent care has received special attention, indicates that institutional 
care will be needed for 12 per cent of the total number of hospital patients 
cared for yearly. Using the 51,840 patients cared for in the ten hospitals 
during 1922 as a basis, it is estimated that, in San Francisco, some 6000 
patients annually require institutional care for convalescence. 

During 1922, the three existing convalescent homes cared for a total 
of 544 patients. As the capacities of two of the homes are being increased 
by some thirty beds during the current year, it is estimated that the exist- 



122 Hospital and Health Survey 



ing facilities can take care of about 1000 of the 6000 cases -needing institu- 
tional care annually. 

Based upon the commonly used estimate of 17 patients to one bed 
per year, 350 beds are required for the 6000 patients. 

Long experience in the larger cities of the country indicates that these 

accommodations should be apportioned as follows: 

Beds , 

Adults — 15 years and upwards — General medical and surgical con- 
ditions -. . 120 

Children — Boys 6-12 and girls 6-15 — General medical and surgical 

conditions, including orthopedic and heart disease •,-..•" 100 

Boys — 10 to 15 years 30 

Mothers with infants and young children (averaging 60 patients).. 30 

Special facilities for cardiacs 40 

With but 110 beds available or even planned for, and lacking provi- 
sions for many special patient groups, the facilities are entirely inadequate. 
In view, however, of the generally high level of living and the relatively 
small percentage of dependency, it is possible that San Francisco may not 
need to provide as extensively for institutional convalescent care as the 
communities on whose experience the estimated number of convalescent 
beds needed is based. 

It may be found expedient to collect information over a definite 
period, in order to verify or correct the estimates herewith presented. The 
exact extent to which provision should be made could be determined by 
a collective study undertaken uniformly in each hospital, such a study to 
include the collection of medical opinion relative to the particular con- 
valescent needs of individual patients, namely, whether institutional con- 
valescent care, home-nursing care, vacation camp, etc., is needed. These 
facts, correlated with facts as to the adequacy of the home conditions for 
the type of convalescence required, would furnish the desired information 
regarding the particular patient groups for which provision should be 
made. Thus one of the groups which will require early and special 
attention is the orthopedic child. The opening of the Shriners' Hospital 
will probably add considerably to the number of such children needing 
long periods of convalescent care. The admirable facilities and achieve- 
ments of Drexler Hall suggest the desirability of similar facilities for 
boys, and for part-pay patients, both boys and girls. 

The convalescent institutions have invaluable first-hand information 
regarding the special groups for which provision is needed, and could 
assist considerably in any joint program for the solution of the problem. 
Their work, conducted with small general recognition of the highly impor- 
tant services they render, is founded on the modern idea that convalescent 
homes should provide not only medical supervision, but also facilities 
for upbuilding and education in health habits. 



Services for the Sick 123 



Chapter 6 

HOMES FOR THE INCURABLE AND CHRONICALLY SICK 

A comprehensive study of the institutional care of the chronically sick 
has been recently made throughout the United States and Canada in 
response to a widespread feeling that the problem has not yet received 
the recognition it deserves. The report 12 briefly states the problem: 

"A chronic patient may be described as one who requires hospital care for 
a period of from three months to several years. From the point of view of 
institutional care, these patients may be grouped into three categories — Class A, 
those requiring medical study for diagnosis and treatment; Class B, those requir- 
ing nursing care only;. Class C, those requiring custodial care only." 

The report stresses the complexity of the problem of caring for these 
various groups and the different types of institutional care demanded, and 
is clear-cut in stating standards regarding the facilities which should be 
available for the three groups : 

'The proper care of a Class A patient demands a complete hospital organi- 
zation with a resident staff, an attending staff on which all of the specialties are 
represented, complete laboratory, X-ray and operating-room equipment, skilled 
nursing and dietetic management. Class B patients require much less specialized 
attention, but should command an excellent nursing service, controlled by a con- 
scientious medical staff. Class C patients need the least care. As the classifica- 
tion implies, the treatment of this last group is largely, custodial in character. 
These patients are retained in an institution; not because they require hospital 
care, but because poverty makes home care impossible. The problem is economic, 
not medical. All of their wants are supplied with due regard to their respective 
disabilities by proper sleeping and living accommodations and food." 

San Francisco has two institutions planned and equipped for the care 
of the chronically sick, namely: 

(a) Hospital of the Relief Home for the Aged and Infirm, conducted 
for indigents by the Board "of Health. 

(b)" San Francisco Home for Incurables, a privately controlled insti- 
tution. 

The accommodations and facilities available in these two institutions 
may be briefly stated: 

(a) Hospital of the Relief Home for the Aged and Infirnv—The Hos- 
pital of the Relief Home, with a capacity of 500 beds, accommodates a 
number of widely different groups, as follows : 

Men Women 

Arrested Tuberculosis (aged chronic) 1 25 

Cancer '.-. .-. 25 '20 

Paralytic 60 25 

Aged Chronic '.'.'. , 160 45 

Custodial 100 40 

Totals 370 130 500 

12 Dr. Ernest P. Boas. Director of the Montefiore Hospital for Chronic Diseases, New 
York, and Dr. A. K. Haywood, Superintendent Montreal General Hospital, Montreal, 
Canada. Modern Hospital, July, 1923. 



124 Hospital and Health Survey 



As the hospital is also the infirmary of the Relief Home, there is a 
constant interchange of inmates back and forth between the Hospital and 
the Home units. 

The physical condition of the 1244 inmates in the Home and Hospital 
sections on July 21, 1923, indicates to some extent the complexity of the 
hospital and custodial problems existing in this type of public institution: 

Men Women Total 

Epileptic 16 6 22 

Blind 29 6 35 

Deaf 28 12 40 

Mentally Incompetent 71 58 129 

Crippled ...116 31 147 

Bedridden ! 120 43 163 

Able to Work 297 31 328 

Old and Infirm 283 97 380 

Totals 960 284 1244 

Due to the fact that the Hospital and Home statistics are not sepa- 
rately assembled, facts as to the number of these which were hospital 
patients, were not available. It was stated, however, when the institution 
was visited, that the patients in the Hospital numbered approximately 300, 
many of the deaf, blind, and crippled not in need of hospital care living 
at the Home. 

The medical service available for the 300 patients consists of two phy- 
sicians who attend every morning and are on call at all other times, one 
of them living on the grounds ; specialists being available for consultation 
when needed. There are no resident physicians or interns. The six medi- 
cal students who work in the Hospital at night do not serve in an intern 
capacity, but as orderlies. 

The Hospital has no laboratory, all laboratory specimens requiring 
examination being sent to the San Francisco Hospital. Patients requiring 
X-ray examinations are sent either to University of California Hospital, 
but four minutes from the institution, or to the San Francisco Hospital. 

The nursing of bed patients is performed by aged inmates of the 
Home, working under the direction of nine trained nurses. 

The planning, preparation and service of food is not under the super- 
vision of a trained dietitian. 

There is no social service department. 

As no separate records are kept for the Hospital section, there was 
no information assembled which would indicate the number of sick receiv- 
ing hospital care, the medical conditions cared for, results, etc. 



Services for the Sick 



125 



The statistics for the fiscal year ended June 30, 1923, which reflect 
to some degree the sickness problems involved, were as follows : 



Admissions — 1922 

Men 

Through Board of Health 613 

From San Francisco Hospital 259 

By Superintendent (readmissions) 31 

Totals 903 



Women Total 



157 


770 


78 


337 


8 


39 



243 



1146 



Discharges — 1922 

Men 

At own request 403 

Died . 249 

Left without permission 105 

Overstayed pass 55 

Sent to San Francisco Hospital 48 

Sent to State Hospital 13 

Sent to Tuberculosis Hospital 7 

Totals 880 



Women Total 



114 


517 


118 


367 


5 


110 


7 


62 


7 


55 


8 


21 





7 







259 



1139 



Ages of Inmates — 1922 

Men 

20 to 30 9 

30 to 40 26 

40 to 50 51 

50 to 60 143 

60 to 70 300 

70 to 80 312 

80 to 90 109 

90 to 100 10 

Totals ..960 

Average age of inmates, 66.88 years. 



Women Total 






9 


3 


29 


20 


71 


42 


185 


88 


388 


74 


386 


51 


160 


6 


16 



284 



1244 



Deaths— 1922 

Men 

30 to 40 . . 3 

40 to 50 .10 

50 to 60 34 

60 to 70 75 

70 to 80 92 

80 to 90 34 

90 to 100 1 

Totals 249 



Women Total 



2 


5 


4 


14 


14 


48 


36 


111 


38 


130 


22 


56 


2 


3 



118 



367 



126 Hospital and Heai/th Survey 



The financial report of the institution shows a. total per capita mainte- 
nance cost for inmates of $.706 a day, made up of the following cost units: 

Unit Costs— 1922 

Subsistence $.245 

Tobacco 014 

Clothing 025 

Fuel ; ... . .037 

Drugs, Medical and Surgical Supplies...... ., .014 

Miscellaneous Items, new equipment, repairs, etc .143 

Total . .... $.478 

Payroll, employes 179 

Payroll, inmates 049 

Total i $.706 

Compared with standards of care quoted earlier in this chapter, the 
facilities maintained by the city for its indigent infirm and chronically sick 
suggest the need primarily for increased expenditure of funds to provide 
better hospital standards. With no separate costs available for the hos- 
pital, the per capita amount expended for the care of the sick is not known, 
but the observations of the Survey and the opinions of local social workers 
familiar with the conditions, force the conclusion that the city has not been 
liberal in the amounts allowed for hospital maintenance and medical and 
nursing care at the Relief Home. It was understood that the immediate 
expansion definitely planned for at the institution does not include changes 
in the hospital, but that a program for increased facilities for the sick at 
some future date not yet determined has been arranged. 

(b) The San Francisco Home for Incurables — The San Francisco 
Home for Incurables admits full pay, part pay and, in some instances, free 
chronically sick patients, including both bedridden and ambulatory cases. 
Patients requiring hospital care are not received, as the institution is not 
equipped to care for them. 

The Home has a capacity of thirty-nine, as follows: 

Beds 

In wards for women 4 

In wards for men 5 

In double rooms , 10 

In single rooms 20 39 

The conditions received are mainly paralysis, senility, arthritis, etc. 
Patients with disturbed mental conditions, drug addicts, and alcoholics are 
excluded. 

The turnover of cases is low, as there were only 34 admissions, during 
1922. There were 29 discharges, 16 of them deaths. 

The institution has a high percentage of use, and is adding a new 
wing providing eight rooms for the use of women with incurable or non- 



Services for the Sick 



127 



operative cases of carcinoma, and similar accommodations for men are to 
be constructed in the near future. The experience of the Home indicates 
there is at all times a demand for beds, on an average of three cases a 
week being refused because of lack of room. It is the opinion of those 
connected with the Home that at least forty more beds could be used, if 
available. 

The institution is maintained at a per capita cost of $2.40 a day, but 
the financial data furnished were not sufficiently complete to permit of 
analysis. 

The arrangement and equipment of the building and the directing 
policies reflect excellent management. It is believed that the publication 
of an annual report of the institution's activities would awaken further 
interest in the problem of the care of the chronically sick. 

The opinions expressed by many physicians, nine hospital executives, 
and over two-thirds of the health and social workers replying to direct 
inquiry on the subject, appear practically unanimous regarding the inade- 
quacy of the facilities afforded by these two institutions. A few of these 
opinions, herewith presented, indicate that the subject offers definite prob- 
lems, as follows : 

"The care of the aged and infirm is a decided problem, due to the inade- 
quacies of our institutions and the lack of visiting nurse care in the homes." 

"The Home for Incurables provides a very excellent service for those who 
can pay a moderate amount. Reduced rates are given to certain patients, but the 
accommodations of the home are very limited. The service for chronic patients 
at the San Francisco Relief Home does not meet the standard of the patients 
nor their friends. The city has not provided the money necessary to maintain 
hospital service, and patients transferred from the San Francisco Hospital to 
the Relief Home feel very bitterly the change of standards. There is the greatest 
need for the development at the Relief Home of a hospital for chronic cases 
with hospital standards, with a medical staff, adequate nursing facilities and diet 
that is appetizing and tempting to those who are chronically sick. It is believed 
that the Supervisors and people of San Francisco would willingly pay the cost 
of such a standard if those who are directing the social work of the city make 
an organized demand for it. It has, however, been fallaciously assumed that 
money for this purpose would be provided at the expense of money needed for 
curable patients who were acutely ill. There is, however, no question that the 
need of the curable patients should have precedence, but in a community as 
wealthy as San Francisco there is no reason why both should not be provided 
for. There is a special need for the development of proper care for incurable 
cancer patients. From our experience, I believe a study of the situation would 
show that the majority of hopeless cancer patients discharged from San Fran- 
cisco Hospital referred to the Relief Home, refused to go there and either return 
to rooms in lodging houses or to their own homes, where they cannot receive 
the care they need, especially in the later stages of disease." 

"In regard to facilities for chronically ill who could afford to pay, I believe 
that there is need for additional facilities at a moderate price. What is really 
needed is a semi-charitable home where people of small means can care for their 
chronically ill, at, say, not over $50 a month. There is nothing in San Francisco 
today that meets this problem." 

"Institutional care for chronic patients is inadequate for free and part-pay 
patients, particularly for cancer cases." 



128 Hospital, and Health Survey 



"Institutional care for chronic patients is practically lacking for those who 
can pay." 

'The placing of the totally blind who are without funds and cannot follow 
their former vocation owing to their physical debility is most difficult." 

The result of insufficient or inadequate facilities for the chronically 
sick is commonly shown in the extent to which beds in general hospitals 
arc used for long-term patients — that is, patients remaining for three 
months or more. 

The census of June 21 showed an extensive use of the hospitals 
for long term patients. Of the 1805 cases, some had been hospitalized 
from five to ten years and over, and many for more than a year. As 
shown in the accompanying table, 169 patients — 9 per cent of the total 
number — had been in the hospitals three months or longer: 

Long Term Patients in General Hospitals* — June 21, 1923 

Time in Patients 

Hospitals No. Pet. 

10 to 15 yrs 2 1 

5 to 10 yrs 2 1 

1 to 5 yrs 41 24 

S mos. to 1 yr.. 17 10 

4 to 8 mos 66 40 

3 to 4 mos 41 24 



A 


-ge- 







Sex 






-Rate 


of Payment — 


Adults 


Children 


M. 




F. 


F. 


Pay 


P. Pay Free 






2 


• ♦ 




2 






2 


1 




1 


2 




4 # 




. 


2 


26 




15 


22 




19 




13 


10 18 


13 




4 


12 




5 




5 


1 11 


48 




18 


39 




27 




28 


11 27 


34 




7 


28 




13 




15 


7 19 



169 100 122 47 104 65 61 29 79 

(72%) (28%) (61%) (39%) (36%) (17%) (47%) 

See lists of long-term patients, Section V, page 150. 

It is evident that on this one day the patients hospitalized from 
four to eight months constituted well over a third of the long term cases, 
those from one to five years and from three to four months constituting 
each about one quarter. The high percentage of adults reflects the 
scarcity of facilities for the adult chronic patient; and the percentages 
of full pay, part pay and free cases, the economic groups for which 
institutional care is sought. As the per capita cost of care in a hospital 
for the acutely sick is more than double that of an institution for chronics, 
it is apparent that the free care furnished the 108 part-pay and free 
patients is an expensive form of charity. 

It is not presumed that all the 169 patients are chronically sick, as 
the mere fact that patients are hospitalized for a three months' period or 
longer does not necessarily mean that they are not properly hospital cases. 
But even a brief study of the diagnoses of these patients suggests the prob- 
ability that at least 90 per cent do not belong in general hospitals main- 
tained for the acutely sick. 

The problem of the chronically sick could properly be made a subject 
of special study by a committee of the proposed Hospital Council. The 
facts made available through the national study previously mentioned 



Services for the Sick 129 

would furnish valuable aid in formulating standards and developing a 
program. 

The sympathy and understanding with which so many free patients 
have been maintained without charge or at exceedingly low rates for so 
many years, justifies the opinion that the individual hospitals have a con- 
siderable knowledge of the patient groups for which provision should 
be made, invaluable in the study of the problem. 

Increased social service facilities for all hospitals, and particularly 
at the San Francisco Hospital, would be of material assistance in dealing 
with the type of problem presented in the chronic patient. The estab- 
lishment of a visiting nurse service would make it possible to care for 
a certain number of chronic patients in their homes. This has been the 
experience of many other localities. For example, the Victorian Order of 
Nurses in Montreal maintains two visiting nurses, especially selected 
because of their personal interest and fitness, who care only for cancer 
patients in their homes. 

Although the number of long-term patients in the hospitals furnish 
some index of the chronically sick for whom special institutional provision 
should be made, any well considered plan for this patient group would 
naturally include consideration of the service which would be available 
through, 

(a) Increased social service. 

(b) The establishment of a visiting nurse service. 

(c) Increased facilities for hospital care at the Hospital of the 
Relief Home. 



REGIC 






TOM 



of Counties 

SAN FRANCIS 



SECTION IV 

Recommendations 



Chapter i 

GENERAL POLICIES 

While it is recognized that the elementary reason for the association 
of the privately supported agencies operating for the prevention and relief 
of dependency and disease, as members of the Community Chest, was to 
reduce duplication of appeals for funds and to secure adequate pro- 
portionate support for all such community services as seemed to be indis- 
pensable, the organization of functional committees and the undertaking 
of this survey express a determination on the part of the officers of the 
Chest to direct inquiry into the social causes and results of preventable 
sickness, as well as to relieve manifest distress, to crystallize public opinion 
in the field of health promotion, and to prepare plans for better services 
capable of using all the resources of the community for the care of sickness 
and the protection of health. 

'The holding of public confidence through educational work all the year 
round, is the rock upon which the success of a federation must.be built. Success 
or failure in raising the combined budget is not a cause, but an effect of public 
understanding." 

"How can the Community Chest vitalize community social work by securing 
active, continuing personal participation in the work of individual agencies? Fed- 
erated financing, by freeing the agency executive of the burden of money raising, 
gives him an unexampled opportunity for enlisting the interest of thoughtful people 
in the work of his particular agency, without regard to the size of their monetary 
contribution." (Survey — June 15, 1923.) 

While it is obvious that there should be justification for the expense 
of a survey in the specific recommendations dealing with appropriations 
requested by individual institutions, it has been understood that policies, 
plans and programs affecting existing public tax-supported agencies, or 
dealing with proposed new private agencies should be considered whether 
or not they afifect the financial obligations of the Chest. 

The scheme of organization of the Community Chest of San Fran- 
cisco is such that while proper control of finances is vested in a group 
chiefly experienced in business and commerce, excellent protection of the 
interests of the professional groups responsible for the technical services 
to the community is provided through representation from the important 
committees such as that on Hospitals and Health Agencies. 

It is believed to be the wise policy, for the present at least, for the 
Community Chest to use its position to sponsor or disapprove of fund 



Recommendations 



131 



raising for endowment or building purposes, but not to participate in efforts 
to add to the capital account of any of the agencies or institutions for the 
current expenses of which it now makes appropriations. 

If the Community Chest makes an appropriation to a hospital or dis- 
pensary on the basis of the amount of service to the sick for which the 
hospital is not paid by patients, it is obvious that such a hospital must 
agree to accept patients for care even when these are not able to pay, 
as long as there are services available appropriate to the needs of the 
applicant. 

Of the twenty cities* of over 100,000 population in the United States 
and Canada where federated fund raising and central control of distribu- 
tion of voluntary contributions were in effect as of June, 1-923, appropria- 
tions were made to some or all of the privately supported hospitals of 
the community in all but three instances (Denver, Minneapolis and Port- 
land, Oregon), although the sums allotted to hospitals in many instances 
were often only to meet the expense of social service work for the patients. 

In a bulletin (No. 12) upon the Non-Financial Activities of Federa- 
tions and Chests, issued in June, 1923, by the National Information Bureau, 
a great majority of the sixty-six communities reported upon included 
in the functions of the Chest or Federation very important non-financial 
activities. 

Among the benefits which Community Chests have brought to a 
number of cities are: study of the community as a whole to permit of a 
reasoned diagnosis of social, economic and health problems ; central col- 
lection of facts as to the service of all similar agencies; standardization of 
practice in reporting upon the operation of hospitals, based upon uniform 
bookkeeping methods. 

To accomplish these results in San Francisco it will be found neces- 
sary to establish a Hospital Council upon which there will be represented 
the managing board and the administration of each hospital whether or 
not the hospital receives funds from the Chest. A central purchasing 
bureau would probably be the first activity of such a council. 

It will probably be found as progress is made in the co-ordination of 
agencies dealing primarily with health, as distinct from sickness problems, 
and in the formation of a hospital council, that the Committee on Hospitals 
and Health Agencies of the Council of Social Agencies will be concerned 
almost wholly with the health work and will need some one trained in 
collecting and interpreting the facts upon which policies in health ad- 
ministration and education are based, to act as a permanent secretary. 

♦Cincinnati, Grand Rapids, Montreal, Canada; Portland, Oregon; St. Louis, The 
Oranges, N. J.; San Francisco, Toledo, Ontario; Minneapolis, Philadelphia, Cleveland, 
Kansas^City, Oakland, Rochester, St. Paul, Dayton, Milwaukee, Detroit, Seattle, Denver. 



132 Hospital and Health Survey 



Chapter 2 

DEALING WITH THE APPROPRIATION OF FUNDS BY THE COM- 
MUNITY CHEST TO THE PRIVATELY SUPPORTED 
HOSPITALS AND HEALTH AGENCIES 

It is understood that appropriations for capital account are not con- 
sidered to come within the scope of the Community Chest at present. 
Therefore, under this section of the recommendations only such items 
will be considered as are properly included under current expenses, or 
maintenance and operation. 

Before offering suggestions as to appropriation by the Community 
Chest to hospitals which are now receiving or have applied for funds, 
the principles upon which allowances from a common purse should be 
made to agencies giving care to the sick should be agreed upon. 

Inasmuch as the interest of the contributor to a community chest is 
theoretically not in institutions but in services to his fellow citizens who 
may be sick or indigent, we should measure the right of a hospital, dis- 
pensary or other agency for care of the sick or protection of health to 
participate in the fund collected, by the quantity and quality of services 
which the particular institution or agency can show from its books have 
been rendered, which have not been paid for by the patients or through 
other earnings, or endowments. 

Two other bases are now in general use to determine the amounts 
to be appropriated to hospitals, that of the deficit in annual operations, 
and that of the sum of voluntary contributions from the public in recent 
years, the use of either of which may be justified as a temporary expedient 
pending the collection of comparable facts as to the amount, quality and 
cost of service given, but neither of which should be adopted as a con- 
tinuing policy by a community chest or welfare federation. 



O" 



It will presumably always be a matter of pride and rivalry anion 
hospitals not only to give as high a quality of medical service as the 
patient needs but to provide this at as low a cost as good administration 
permits. 

Since no fair basis of measurement of quantity, quality or cost of 
hospital or dispensary care can be arrived at among the hospitals of 
San Francisco until modern accounting methods and departmental records 
of service and unit costs are adopted, approximately on a uniform basis 
by all the medical service institutions, and until the services are so reported 
that the number of days of hospital care, or the number of visits of 
patients to dispensaries can be classified according to the main medical 
groups, such as medical, surgical, obstetrical and children, and according 
to their financial relation to the hospital, i. e., free, part-pay or full-pay 
patients, and the cost of services can be reported upon by substantially 
these same groups where practicable, no institution can make its right to 



Recommendations 133 



a particular sum from the Community Chest clear to the Trustees of the 
Chest. 

It is to be clearly understood that in calculating the cost of hospital 
and dispensary care there should be included the expense of laboratory 
diagnostic procedures and special therapeutic treatments, as disclosed by 
an accounting for the operation of these services, not as based upon 
arbitrary schedules of prices charged, comparable to those of commercial 
organizations operating for profit. 

It is obvious that there will be considerable variation in the cost of 
essentially similar services given at different hospitals, according to the 
comfort, space, character of personnel, housekeeping standards, etc., and 
it may prove necessary for the Chest to establish a maximum per capita 
cost of care for bed and dispensary patients, beyond which the cost of 
treatment of the sick will not be met, except where there is some par- 
ticular or special treatment unobtainable elsewhere, and essential to the life 
and health of individual patients. 

It is recommended that : 

1. Basis for 1924 Appropriations — Appropriations for 1924 to hospi- 
tals and dispensaries be continued on the same basis as in 1923, although 
this is recognized as an unsuitable permanent or continuing financial policy. 
The principle upon which appropriations should be made, namely, for such 
amounts as can be shown by a hospital or dispensary to have been spent 
for the care of the sick which patients have not met in whole or in part 
by their own payments for care, cannot be adopted until next year, 
because it will not be possible in a shorter period to institute in the 
hospitals and dispensaries such a system of cost accounting and book- 
keeping as will permit monthly reports to the Community Chest of the 
services rendered to free, part-pay and full-pay patients, and their cost. 

As soon as practicable after such a system is put into operation in 
any hospital or dispensary the Community Chest should use the monthly 
reports of hospital operation and the costs of free services as the basis 
of annual allotment of funds to these institutions, having in mind at the 
same time the importance of providing for improvement in quality and 
completeness of service as well as the propriety of meeting the cost to 
which an institution has been put in caring for the sick of the community 
who could not pay all or any of the expenses of their treatment. 

2. Franklin and University of California Hospitals — That special 
reconsideration be given to the matter of appropriations to the Franklin 
Hospital and to the Women's Auxiliary of the Out-Patient Department 
of the University of California Hospital: 

(a) Franklin Hospital — In the case of the Franklin Hospital (which 
received an appropriation of $15,000 in 1923), a subsidiary of the German 
General Benevolent Society, organized for sickness insurance and other 
purposes on a commercial basis, the hospital appears to have closed its 
year's operations in 1922 with a profit of $545, which was applied to a 
reduction of the $34,195 deficit shown on the books of the benevolent 



134 Hospital, and Health Survey 



association. Furthermore there appear to be carried on the pay roll of the 
hospital the salaries of four physicians whose functions are solely to serve 
the members of the Benevolent Society. In estimating the cost of free 
service provided by this hospital to the sick of the community these salaries 
should not be included. 

(b) University of California Hospital — As to the Women's Auxiliary 
of the (Hit- Patient Department of the University of California Hospital it 
is suggested that it is an unwise policy for the Community Chest to make 
any appropriation for services to the sick which are supplied by a hospital 
supported by city or state taxes. Social service differs in no essential 
from various other hospital or dispensary services of a professional nature. 
The fact that the Regents of the University have not seen fit to provide 
for all the medical social service which is found necessary at this hospital, 
while they have supplied funds adequate for dietetic, anesthetic, nursing 
and other services of a professional character, is a matter of much public 
interest, but it is not conceived to be the duty or proper function of private 
agencies, using funds collected through voluntary contributions, to select 
one particular essential function of a state tax-supported hospital and re- 
lieve the tax levy of this burden. 

Such part of the funds which have been spent by the Women's 
Auxiliary of this hospital, as have been used for material relief of the 
indigent sick, should be provided through existing general relief agencies in 
the city. 

It is quite possible that the Community Chest may feel that the 
medical social service provided in the interest of the patients of the 
University of California Hospital is too important to allow it to lapse 
until the State provides for it. If so, is it not obviously the duty of the 
Chest to provide for similar service at the San Francisco Hospital, where 
the city has not yet installed it? 

With regard to appropriations requested by the University of Cali- 
fornia Hospital to meet the cost of care of free or part-pay patients, 
resident in San Francisco, it is considered that subsidizing a tax-supported 
public hospital through charitable funds would be a fundamentally wrong 
principle to establish. 

3. Lane and Stanford University Hospital — With regard to the 
requests of the Stanford Clinics Auxiliary and the San Francisco Ma- 
ternity, and the Lane and Stanford University Hospital it is recommended 
that these be granted in 1924 as in 1923, but it is suggested that in the 
future no separate appropriations for hospital or dispensary services for 
free and part pay patients be considered. All hospital departments should 
be under the direct administrative supervision and control of the super- 
intendent through whom all requests for funds should go to the managing 
board of the hospital, the latter to approve appeals for appropriation from 
the Community Chest. The facts that Lane and Stanford University 
Hospital received no money from city or State taxes, that it is the hospital 
of an important teaching institution, and that, coupled with high-grade pro- 
fessional and nursing services, there has been provided a medical social 



Recommendations 135 



service department of excellent quality, all seem to justify particularly 
favorable consideration of the request for such funds as will permit this 
hospital to offer more beds for the care of free and part-pay patients. 

4. Osteopathic Clinic — It is recommended that no appropriation be 
made to the Osteopathic Clinic for the reason that the services for the 
sick are of a quality too low for the Chest to sponsor. It is doubtful if 
anything* approximating adequate or responsible diagnosis and treatment 
of disease, as these are understood and practiced in the other medical 
institutions assisted by the Chest, is to be had at the Osteopathic Clinic. 

5. French Hospital — It is recommended that no funds be granted 
to the French Hospital of the Societe Francaise de Bienfaisance Mutuelle. 
It appears from the report of the Society that in 1922 of the 46,766 days of 
hospital care provided, but 103 days of care were given to patients who 
paid no part of the cost of their hospital services. 

It appears that in 1922 the fees of beneficiaries of the Society, a sick- 
ness insurance association, organized on a commercial basis, which operates 
the Hospital, together with fees of other pay patients, met all operating 
expenses and left a balance of profit for the year of $14,092. 

6. Mary's Help and St. Marys Hospitals — A situation exists in 
Mary's Help and St. Mary's Hospitals peculiar to hospitals managed by 
Catholic Sisterhoods where many of the professional, nursing, administra- 
tive and office positions are filled by Sisters, for whose salaries no sum is 
set aside in the hospital budget equivalent to the amount which would have 
to be paid at prevailing rates for these services. 

The Community Chest would be justified in making appropriations for 
the present to these two Catholic hospitals on the same basis as in the 
case of other privately supported hospitals, but several situations brought 
about in the financial status of the Sisters' hospitals by the gift of their 
services require consideration before establishing a definite policy for the 
future. 

It appears that at St. Mary's Hospital, in 1922, income exceeded ex- 
penditures to the extent of $31,207, which is $7807 more than the hospital 
would have had to pay for Sister services if the usual rates for equivalent 
positions had been paid here as in the case of other hospitals in San 
Francisco. The profit shown on the books for 1922 — $31,207 — was added 
to the capital account of the hospital, and any appropriation of the 
Community Chest to this institution under these conditions would to all 
intents and purposes constitute a contribution to the hospital's building 
fund, an objective alien to the purposes of the Community Chest at present. 

Similar facts cannot be presented for Mary's Help Hospital, as this 
institution did not furnish a complete financial statement. However, it is 
estimated that the Sisters' services for hospital purposes represent a sum 
of $14,700 a year, at present rates for equivalent positions. 

When the cost of hospital or dispensary care of free and part-pay 
patients at either of these two hospitals is presented, as suggested in the 



136 Hospital, and Heai/th Survey 



introductory remarks of this section, there should be shown as a book- 
keeping item of hospital expense a sum equivalent to the estimated value 
of such Sisters' services as are devoted to hospital work, and the per 
capita cost oi care per day or the cost of a dispensary visit should be 
based on a total of expenses which includes this item. 

7. Proposed Hospital Council — It is recommended that for 1924 the 
Community Chest provide the funds necessary to meet the cost of a Hos- 
pital Council, the functions of which would be ultimately as suggested in 
Section III, but for the present should consist, so far as paid services are 
concerned, of a central record office and purchasing bureau supplied with a 
modest revolving fund to permit of the taking advantage of cash discounts, 
etc. It is believed that an initial annual expenditure of not over $15,000 
would show savings to a considerably greater amount in hospital expendi- 
tures and at the same time provide the opportunity and occasion for a 
continued and current study of all hospital problems. 

8. Secretary to Proposed Health Council — It js recommended that 
the position of Secretary of the proposed Health Council be created in 
the offices of the Community Chest or Council of Social Agencies, such 
a position to be held preferably by a physician qualified in public health 
work, possibly on part time, the functions of this office to be as described 
in Section II, but at least to include those of executive officer of the 
proposed Health Council under which he would initiate and share in 
carrying through more detailed studies of the health services of San 
Francisco than w T as found possible during the Survey herewith reported. 

9. Assistant to Division of Child Hygiene of the Department of Public 
Health — It is recommended that until the city provides the funds, the 
Community Chest appropriate up to $5000 towards the salary of a full- 
time physician to assist the Health Officer in developing a complete pro- 
gram of Child Hygiene as outlined in Section II. 

It is not considered a proper policy for a city employe to be paid by 
a private organization, nor that a private agency should decide upon and 
pay salaries to those in public office or serving public functions, which 
are out of proportion to the salaries paid on the city budget. However, it 
ought to be possible to make available to the Health Officer and for public 
service in that field an assistant whose salary the city would soon meet ; 
such a person, for instance, to supplement rather than replace the present 
part-time physician, head of the Bureau of Child Hygiene of the Health 
Department, and to be responsible to him. A precedent for such private 
subsidizing of city health personnel has occurred in the field of tuberculosis 
work, where salaries of Department of Public Health nurses were for a 
time met by the San Francisco Tuberculosis Association and from private 
contributions. 

10. Hospitals Establishing Social Service Departments — It is recom- 
mended that the Community Chest encourage each of the hospitals and 
independent dispensaries to which it may allot funds for general maintenance 
and support, to establish medical social service under its own independent 
direction, and that, to secure the early establishment of such an essential 



Recommendations 137 



professional service in connection with the medical and nursing services 
as they are now usually organized, the Community Chest offer to meet 
the expense of at least one trained medical social worker in each of 
the assisted institutions. 

It may be found impracticable for the San Francisco Hospital to add 
an adequate medical social service to its existing hospital facilities, as 
promptly as is recognized to be desirable by the Board of Health, the 
Health Officer and the Superintendent of the Hospital. Until such time 
as this service, of particular value to the sick poor of the city, for 92 
per cent of whom the San Francisco Hospital provides bed care, is estab- 
lished and maintained out of the tax levy, it is probable that through joint 
action of the relief agencies much could be done to remedy the incomplete- 
ness of hospital care, as revealed in the study of recently discharged 
patients. For such additional social service if provided by competent 
medical social workers, the Community Chest might be asked to con- 
tribute further to the social and relief agencies. 

11. Establishment of District or Visiting Nurse Association — It is 
recommended that a sufficient sum be set aside in 1924 to meet the expense 
of organizing and establishing a District or Visiting Nurse Association 
under the auspices of the Community Chest or of the Council of Social 
and Health Agencies. 

Educational services and health protective as well as sickness and 
maternity bedside care in the homes, under the direction of the private 
physicians or of physicians of hospitals and dispensaries, are nowadays 
recognized as so fundamental a part of a sickness and health service in 
any community that the establishment of such is strongly urged. In a city 
such as San Francisco, where there are only 1200 families among the 
whole population found to require material relief, it is altogether likely 
that a visiting nurse service for free, part-pay and full-pay patients in 
their homes, such as is contemplated, would soon become at least 60 per 
cent self-supporting. It is of primary importance that the directing body 
or managing board of such an organization be formed of men and women, 
among whom there should be representative physicians, nurses and men and 
women with a knowledge of social and relief work, but the actual admin- 
istration of the services should be left to a Director of Nurses, equipped 
by training and experience in public, health nursing, and wholly untram- 
meled in the sphere of her professional work. 

It is particularly fortunate that just at this time there has been 
completed the first nation-wide study of the organization, costs, and services 
of visiting nurse associations by a committee of the National Organization 
for Public Health Nursing. The report of this Committee's work will be 
available in preliminary form within a month for the use of the Com- 
munity Chest and it is recommended that action in the matter of organiz- 
ing a Visiting Nurse Association await careful consideration of this text. 

12. Convalescent Homes and Homes for Chronic Invalids — It is 
recommended that the Community Chest authorize and use its influence to 
endorse and encourage the raising- of funds for the erection of Convalescent 



138 Hospital and Health Survey 



I Ionics and Homes for Chronic Invalids where those able to pay all or 
part of the cost of their care should be provided for, when they are no 
longer in need of the services and equipment of a hospital primarily 
designed for the care of acute and relatively brief periods of illness. This 
is a matter which concerns intimately the problems of hospital operation, 
for at present an excessive expense is being met by the hospitals for the 
care of many convalescent and chronic invalids who could be as well or 
better provided for at half the daily cost per capita in Homes constructed 
and operated to meet their particular needs. The need of materially in- 
creasing the hospital facilities of San Francisco can be postponed for many 
a cars if adequate provision is made for chronic and convalescent patients 
who now use hospital beds to the disadvantage of themselves and to the 
excessive expense of the hospitals. 

In addition to the provisions planned for or under construction under 
the auspices of the Board of Health at the Relief Home there are now 
needed for the patients improperly provided for in the hospitals of San 
Francisco 100 beds for chronic invalids. There are 265 beds needed for 
convalescent patients. To meet these needs there are at present only 
thirty-nine beds for chronic invalids, and eight more under construction 
for cancer patients, and sixty-nine beds for convalescents, with thirty more 
under construction. 



Chapter 3 

DEALING WITH PROGRAMS IN THE FIELD OF PUBLIC HEALTH 

FOR THE PROMOTION OF WHICH THE COMMUNITY CHEST 

MAY BE EXPECTED TO LEND ITS DIRECTING 

INFLUENCE 

1. Health Education— -First in order of importance in the field of 
health promotion, sickness prevention, and the postponement of death is 
education of the public in the principles of right living and in the means 
of self-protection. 

The two logical and appropriate agencies for carrying on education 
in health are the schools and the Board of Health. There is needed a 
policy, a plan and the practice of education of children in each grade, 
according to their capacities, in the simple biological truths upon which 
health, its establishment and maintenance depend. 

It is not additional teachers or new or more equipment that is needed 
in the schools but such rearrangement of subjects, with such alteration 
of emphasis, example and proportion in the school curriculum as will per- 
mit the teaching of the facts of life in every department. Teaching of 
hygiene, or physical training or kindred subjects as additions to a crow r ded 
curriculum will never accomplish our purpose, which is to have health, 
and knowledge of it permeate the teaching of every topic of the school 
course, and the daily practice of teachers and children. 



Recommendations 139 



A Board of Health which is allowed no appropriation by the city to 
permit the Health Officer to carry out any educational activities except 
through the occasional opportunity of lectures to groups of adults, can- 
not perform one of the most important functions for which it is created. 
A Health Officer who cannot spend the price of a postage stamp to send 
out bulletins on the city's health status, or even assemble and print a record 
of the annual death rate and preventable causes of death, is powerless to 
use his position of influence and high prestige in the community to spread 
the knowledge of health liabilities and assets. According to the conserva- 
tive estimate of reasonable expenditures for health purposes as expressed 
by the report of the Committee on Municipal Health Department Practice 
of the American Public Health Association, the appropriation for health 
education by the Board of Health should, in San Francisco, amount to 
$20,520. 



However much the public agencies for education have to spend, or 
however successful they may be in application of their appropriations for 
this purpose, there will always continue to be a need for organized educa- 
tional effort by all the private agencies operating in the realm of pre- 
ventive medicine. 

It is recommended that the Community Chest arrange . for periodic 
conferences on the subject of health education for the purpose of com- 
mitting* public and private agencies to a coherent and progressive program 
and to attract the attention of the public to this important resource for 
self-protection. 

It is recommended further that a standing committee of the Council 
of Social and Health Agencies or of the proposed Health Council of San 
Francisco be called together to undertake continuous agitation for and or- 
ganization of education of the public in health through all possible chan- 
nels. An uninformed, skeptical, superstitious public is more dangerous 
than a polluted water supply or unpasteurized milk. 

2. Child Hygiene — Only second in interest and probably in im- 
portance to health education is the protection of child life, from the period 
of prenatal existence to the age of independent support on graduation 
from school. 

The program for child health is nowadays so well understood and 
the desirable elements are so generally accepted that little of argument 
or description is required. The following are the important features of 
the existing services which need reinforcement or extension : 

(a) Prenatal supervision of expectant mothers should be extended, 
partly through five additional baby centers which might well be established 
by the Department of Public Health, and partly through the hospitals 
which offer maternity care. Only when a routine Wassermann test is taken 
and supervision, of each expectant mother, following a medical examina- 
tion, is provided for in the last five months of pregnancy, do we find that 
the maximum reduction in maternal and neonatal mortality occurs. 

(b) There is apparently some duplication in the work of the Haight 



140 Hospital, and Health Survey 



Street Center so far as prenatal supervision is concerned, which might 
be eliminated by referring such patients to one of the six prenatal clinics 
operated in connection with large general hospitals. 

(c) Supervision of the 105 midwives should occupy the entire time 
of one nurse of the Department of Public Health. 

( (1 ) Nursing follow-up of mothers recently discharged from hospital 
care is one of the many needs which cannot be met until a visiting 
nurse service is provided which will reach all parts of the city and be 
available for all kinds of patients. 

(e) As many as four additional nurses should be added to the present 
force of the Department of Public Health to permit of supervision of more 
babies at Well Baby stations. 

(f) Detection of nutritional defects of children and institution of 
appropriate remedial measures will never be adequate until in each instance 
the diagnosis and treatment is determined by medical examination of the 
child who shows a weight 10 per cent or more below the usual for the 
height and age of the child. 

(g) The same special diagnostic skill should be provided for such 
children of the preschool or school ages as is recognized as necessary 
in the cases of cardiopathic or pretuberculous children. 

(h) It is recommended that additional provision be made for the 
special consultation clinics for school children organized at appropriate 
times of the day and week, in connection with the pediatric clinics of the 
hospitals of the two medical schools, to which more difficult, doubtful or 
problem cases may be referred by the medical inspectors of the Depart- 
ment of Public Health for opinion. The medical examination of children 
in the schools does not permit of such completeness or accuracy as is 
desirable. These special clinics should provide for the child showing 
mental and behavior disturbances as well as for those with nutritional, 
cardiac or other diseases and disorders. 

(i) There are needed now to provide adequately for the medical and 
nursing supervision of the health of school children not less than eight 
additional nurses, three part-time physicians, a full-time dental hygienist 
and a traveling dental clinic. 

(j) There is needed in each of the eighty-five schools of the citjJ 
provision for at least two classes of thirty children each, operated upon 
the open-air basis. This would accommodate the 5100 children who are 
known to be suffering from malnutrition, anemia, pretuberculous condi- 
tions, etc., who can best be handled in open-air classes. 

(k) The follow-up of the children who leave day school for employ- 
ment, with working certificates issued by the Department of Public Health, 
should be undertaken through the night schools which they are required 
to attend. 

An addition of approximately $30,000 to the present budget of the 
Department of Public Health would meet the need of personnel in the 



Recommendations 141 

field of child hygiene, this to include the salary of the full-time physician 
to lead in organizing a community program in this field. 

3. Tuberculosis — The tuberculosis situation in San Francisco has 
recently been so carefully studied by both local and national organizations 
that little can be added to the program already approved by competent 
authority. 

As long as the reporting of tuberculosis by physicians is incomplete, 
while enough hospital beds are not provided for those in the active oper. 
stages of the disease, and while patients recently discharged are permittee 
or forced by circumstances to return to work, of a kind and amount quite 
certain to determine a return of the active stage of the disease, there will 
be need for increasing and persistent activity on the part of public and 
private agencies. 

Specifically there are needed to accomplish actual control of tuber- 
culosis in San Francisco : 

(a) Education of physicians in the necessity of early reporting of 
cases of the disease, if necessary by pressure through the authority of the 
Board of Health. 

(b) Provision of about 250 more beds for patients in the com- 
municable stage of the disease: 50 for children in wards on the roof of 
the San Francisco Hospital ; 80 for chronic cases of the disease in adults 
who need custodial rather than special medical care, in units to be pro- 
vided at the Relief Home; 120 for early favorable cases, adults and chil- 
dren, who need sanatorium care at the proposed new city institution at 
Redwood City. 

(c) Home supervision and follow-up after discharge from sana- 
torium or hospital care in an arrested stage of the disease, coupled with 
economic rehabilitation, or "industrial convalescence" to be provided by 
supervised occupation, on a part or whole-time basis in a specially ad- 
ministered work shop, and ultimately placement in such work as will offer 
the best chance of avoiding relapse and permit of self-support. 

Public health education as urged above in this chapter and the 
organization of a visiting nurse service throughout the city as proposed in 
Chapter 2 of this section, together with a fuller development of the 
program for child hygiene, should be considered as important elements in 
a satisfactory plan for better control of tuberculosis. 

4. Mental Hygiene — While the requirements of those burdened with 
disabilities of the mind and inadequacies of personality have been largely 
ignored in the past in the plans for care of the sick and in the field of 
preventive medicine, the physicians and others in San Francisco who con- 
stitute an informed group, technically proficient and eager to see adequate 
provision, are in entire agreement as to a program which will correct 
old abuses and failures of service. 

(a) There should be provided at the San Francisco Hospital fifty 
beds for mental disease, for the present in the existing buildings, but 



142 Hospital and Health Survey 



later preferably in a separate unit devoted especially by appropriateness 
of equipment and personnel to the care of acute committable cases. 

(I)) At the University of California Hospital forty beds are needed, 
fifteen for observation and diagnosis, twenty-five for treatment of mental 
disease and all to be used in the teaching of medical students and 
physicians. 

(c) At the Lane and Stanford University Hospital there should be 
provided thirty-five beds, ten for diagnosis and twenty-five for treatment. 

( d ) Out-patient services for mental disease, including psychiatric 
social work, psychological analysis, and sufficient stenographic work to 
permit of competent records, should be developed at the San Francisco 
and Mount Zion Hospitals and at the hospitals of the two medical schools. 

(e) There should be added to the present scope of medical in- 
spection of school children, psychological survey of all, and psychiatric 
study of such children as appear to be abnormal in their mentality or to be 
suffering from disturbances of personality, or in the field of their emo- 
tional life. 

(f) Provision for emergency commitment of persons wdth mental 
disease, and for parole to the supervision of psychiatric clinics or hospitals 
would save much expense of institutional custodial care and in many ways 
contribute to the promptness and humanity of the protection afforded these 
patients. 

(g) A clinic devoted to the study and demonstration of the relation- 
ship between the delinquency of children and adults and mental diseases, 
would serve the schools, the courts, and the social agencies, and might be 
expected to disclose the fact that two-thirds of the problems of dependency 
and crime have their origin in errors of .mentality and behavior as has 
been shown in other large cities of the country. 

5. Venereal Diseases — What is known as "The American Plan" for 
venereal disease control is so well known that any detailed recommenda- 
tions based upon it would appear superfluous. Furthermore it is now fully 
recognized that only by a plan which includes educational, recreational, 
social, religious and legal as well as medical and public health measures 
will any marked or permanent impression be made on those relationships 
which largely determine the extent of infection of a community with 
syphilis and gonorrhea. 

(a) It is recommended that more effective measures, through official 
action of the County Medical Society, through appeals to the conscience 
and sense of public responsibility of the individual physician, and through 
the pressure of the authority of the Board of Health, be taken to obtain 
a more general reporting of venereal diseases as required by State law and 
local ordinance. 

(b) More clinic facilities are needed to provide for early accurate 
diagnosis and thorough treatment of those who do not require hospital 



Recommendations 143 



care, and to supply the necessary follow-up which will insure the patients' 
return for treatment until their infections are cured. 

(c) The present practice of the privately controlled hospitals to 
exclude such patients from their wards and. rooms as require hospital 
care for active syphilis and gonorrhea in the communicable stages of these 
diseases should be" abandoned, and patients, whether on the free, part-pay 
or full-pay basis, should be provided for, if necessary in wards and rooms 
set apart for venereal diseases. 

(d) A committee of the proposed Health Council should be organized 
to consider all phases of the problem of venereal diseases, and to plan 
for such measures as will reduce exposure to and infection by syphilis and 
gonorrhea. 

6. Heart Diseases — The entry of heart diseases into the class of 
preventable disorders is relatively recent, but enough is known of the 
primary causes, and of the reasons for development of increasing dis- 
ability and* premature death from heart affections to justify the preparation 
of a program for prevention and relief. While San Francisco provides 
some of the elements for such a program, there is still inadequate provision 
for diagnosis and medical supervision of the cardiopathic child of school 
age, there is no channel for public education in the matter of prevention 
of heart diseases, there is no place where either convalescent or chronic 
cardiac patients can be cared for outside of general hospitals, there is no 
trade school training for children handicapped by a disability of the heart, 
and requiring a special vocational guidance, and there is no placement 
bureau for wage earners where patients from hospitals and clinics can be 
provided with employment suited to their disabilities and yet permitting 
self-support. 

7. Cancer — The peculiarly high cancer mortality in San Francisco, 
even if it proves to be due chiefly to the relatively high percentage of 
persons over 40 years of age among the population, attracts special atten- 
tion to the inadequacies of service for its prevention and treatment. 

(a) Much more educational work such as has already been initiated 
by leading surgeons of the city is needed, to inform the people of some of 
the easily preventable causes of cancer, of the resources for early and 
accurate diagnosis, and of the necessity of prompt action if a positive 
diagnosis is established. 

(b) Beds, at least in the San Francisco Hospital and in several 
of the other general hospitals, should be kept available for care of cancer 
patients until such time as other provision is made for inoperable, incurable 
invalids from this disease. 

(c) Home nursing, which could be provided only through a visiting 
nurse service such as has been already suggested, is urgently needed for 
the many cancer patients who cannot find accommodation away from 
home, in hospital, or home for incurables under such conditions of privacy 
and care as will be acceptable to those who expect to pay all or part of 
the expenses of such service. 



144 Hospital and Health Survey 



(d ) It is recommended that the Board of Health add cancer to the 
list of reportable diseases and obtain the co-operation of the medical 
profession in reporting their cancer diagnoses. 

8. Health Examinations — It is recommended that an annual health 
examination be arranged for in the case of each permanent employe of the 
public or private hospital or health agencies considered in this report. So 
far as possible this should be provided at the expense of the organization, 
institution or agency and should meet the standards proposed by the 
American Medical Association for such periodic examinations. 



SECTION V 

Forms, Lists, etc. 

FORM NO. 1 

(Form Letter Sent to Members of the San Francisco County Medical Society) 

COUNCIL OF SOCIAL AND HEALTH AGENCIES 

OF SAN FRANCISCO 

Room 516, Sharon Building; Telephone Douglas 9160 

President, Dr. Ray Lyman Wilbur Executive Secretary, Mabel Weed 

Vice-Presidents, Rev. Michael R. Power, Miss Alice Griffith 

19 June, 1923. 



Dear Doctor: 

This is an appeal for information which can be obtained only from physi- 
cians. At the request of the Council of Social and Health Agencies of the Com- 
munity Chest of San Francisco, I am studying the existing hospital, clinic, and 
health services of the city, with a view to determining their adequacy for the 
protection of health, and for care of the sick. 

Can you spare the brief time and attention necessary to answer the following 
questions? Answers to this letter will be held confidential, and only tabulations 
of the facts furnished will be made public: 

1. Are you a member of any hospital or dispensary staff, and in what 
capacity? 

2. Are you connected in an advisory or professional capacity with any offi- 
cial or volunteer health agency, and in what capacity? 

3. Do you have difficulty in obtaining care or service of the kinds suggested 
below for free, part-pay or full-pay patients? 



to 

i— « . 

o 

p 



in 

O 
P 



o 

$>« 

s to 
to l-t 

o o 
o ^ 

p p- 



to 

P- 






to 



o 



< 



p 


zr~ 


-T 





3 


n 


P o 


T> 


-+ en 


^ 




to 


'■)' 




- pj 






1 P 






r> 











oS 

to o> 

o £L 

[-• Q- 
P 
P 
•1 



^ CD 

P p 

£.»> 

o p 

CTQ cl 

o 
P 



r-f- 
P 



Hospital Care. ........ 

Dispensary Treatment 

Home Nursing 

Convalescent Care.... 



1-1-6 Hospitai, and Health Survey 



4. Is it your opinion that more hospital beds or increased dispensary services 
arc needed in this city? 

5. Do you believe that adequate precautions are taken to prevent the abuse 

by patients of tree medical and hospital services? 

6. 1 lease mention any inadequacies of service with which you are familiar 
among official or volunteer agencies dealing with prevention of disease, or treat- 
ment of the sick. 

[f possible, please let me have your reply, in the enclosed envelope, not later 
than Friday, June 22. 

Yours very truly, 

(Signed) Haven Emerson, M. D., 
Director of Hospital and Health Survey. 

Questionnaire tilled out and returned by 

, M. D; 

FORM NO. 2 

(Form Letter Sent to Social and Health Agencies) 

COUNCIL OF SOCIAL AND HEALTH AGENCIES 

OF SAN FRANCISCO 

Room 516, Sharon Building; Telephone Douglas 9160 

President, Dr. Ray Lyman Wilbur Executive Secretary, Mabel Weed 

Vice-Presidents, Rev. Michael R. Power, Miss Alice Griffith 

20 June, 1923. 
My dear 

May I have, as a confidential communication from you, and not to be quoted, 
your answer to the following questions: 

(a) From your experience and observation what, if any, of the following 
facilities for free, part-pay or full-pay patients are. lacking in San Francisco? 

Hospital bed care 

Dispensary or clinic service 

Home or Visiting Nurse Service 

Convalescent bed care 

Institutional care for chronic patients 

Medical Social Service 

(b) Please indicate which of the following classes of patients lack medical 
or social services necessary for their complete recovery: 

1. Medical •. . . . 6. Eye 

2. Surgical . 7. . Orthopedic - 

3. Obstetrical and Gynecological 8. Venereal and Genito-Urinary 

4. Children 9.. Mental and Neurological . 

5. Ear, Nose and Throat 10. Dental 

(c) What services, if any, within or outside of }^our own institution or 
agency, do you believe to be of special importance to render more effective and 
complete the work your institution is responsible for? 

Please do me the great courtesy of returning your answers to these ques- 
tions, in the enclosed envelope, to me not later than Friday, June 22. 

Thanking you for your assistance in this matter, I am, 

Very truly yours, 

(Signed) Haven Emerson, M. D., 
Director of Hospital and Health Survey. 



Forms and Lists 147 



EXHIBIT A 

(Monthly Report Form Used by Hospitals Belonging to the Cleveland Hospital 
Council for Reporting Hospital Statistics to the Welfare Federation of Cleveland) 

STATISTICAL REPORT 
Of the 

HOSPITAL 

To the 
WELFARE FEDERATION. OF CLEVELAND 

I 7 or the 
Month of ,192... 

Section I — Hospital 

1. Patients in Hospital at first of month 

2. Admissions: 

(a) Full pay 

(b) Part Pay 

(c) Free 

(d) Births 



(e) Total Admissions 



3. Total Patients in Hospital during month 

4. Deaths within 48 hours 

5. Institutional Deaths 

6. Discharges 



7. Total Deaths and Discharges 



8. Patients remaining at end of month 

9. Admissions: 

(a) Men 

(b) Women 

(c) Children 14 years and under 

(d) Residents of Greater Cleveland... 

(e) Residents elsewhere 



10. Patient Days' Treatment (Under the classifications given, 

include registered cases remaining less than 24 hours) : 

(a) Medical 

(b) Surgical 

(c) Obstetrical 

(d) Full Pay 

(e) Part Pay 

(f) Free 

(g) Infants 

(h) Total 

11. Operations Performed: 

(a) Major 

(b) Minor 



(c) Total 



348 Hospital and Health Survey 



12. Laboratory Examinations 

13. X-ray Treatments, Pictures, etc 

14. Applicants Rejected (Causes for rejection) : 

(a) Lack of Reds 

(h) Inability to pay 

(c) Cases Unsuitable for Hospital Care 

(d) Disease condition not one which Hospital is fitted 

to treat 

(e) Other causes (specify if possible) 

(f ) Unknown or no record 

(g) Total Rejections 



Section II — Dispensary 

1. New Patients: 

(a) Men 

(b) Women 

(c) Children 14 years and under 



(d) Total New Patients 
Revisits 



3. Total Visits 

4. Give any other facts or figures that may be available. 



Section III — Social Service Work 



1. Ward Visits 

2. Home Visits 

3. Other Visits 



4. Total Visits 

5. Give any other facts or figures that are available. 



Section IV — Additional Items of Service 

(Include items not reducible to statistics — i. e., clinics, educational work, co- 
operation with other agencies, etc. Also publicity material. Use extra pages 
if necessary.) 

Section V — Personnel 

(Report only semi-annually, as of June 30 and December 31) 

1. On Visiting Staff 

2. On Resident Medical Staff 

3. Graduate Nurses 

4. Student Nurses • 

5. Day Nurses 

6. Night Nurses 

7. Other Employes 



8. Total Employes 

9. Number of Employes and Staff who take meals at 

Hospital 



Forms and Lists 



149 



Notes 
1. 
2. 

3. 

4. 

5. 



Pay patients are those for whom at least the cost of their care is paid. 

Part-pay patients are those for whom only part of the cost of their care 
is paid. 

Free patients are those for whose care nothing is paid. (Uncollectable 
bills should not be included under this head.) 

No class of patients or important work performed by the Hospital should 
be omitted from this report. 

Along with these reports, please send any publicity literature, such as 
pamphlets, programs, printed reports, etc., that the Hospital may issue. 

FORM NO. 3 

(Form Used in San Francisco Survey for Collecting Information at Homes of 
Recently Discharged Patients to Determine Convalescent Needs) 

Hospital 

Hospital No Private Patient? 

Name 

Address 

Full Pay Free Sex 

Part Pay (state rate paid) $ 

Dates: 

Admitted Discharged 

Where Referred on Discharge: 

Hospital's Clinic Other Clinic 

Private Doctor S. S. Dept 

Social Agency Other 

Diagnosis 

Condition on Discharge 



Age 



Date of Home Visit 





Provided 


Not P 


rovided 


Patient's Needs 


By 

Hospital 


Suggested by 
Hospital and 
Otherwise 
Provided 


_ 
Suggested 

by Hospital 


Not 
Suggested 






















Home Nursing Care .... 










Convalescent Institutional 
' Care 










Chronic Institutional 










Instruction 










Physiotherapy 










Occupatherapy 










Financial Relief 










Occupational Placement . 










Other Needs 











Status of Patient: 



1^0 Hospital and Health Survey 



LIST OF LONG-TERM PATIENTS 

Patients in Hospitals Over Three Months on June 21, 1923 

(Sec page 128) 

Number of Days 
Rate of in Hospital * 

\ Ag Payment Diagnosis June 21, 1923 



In Public Institutions 



San Francisco Hospital — 



M 


18 


F 


27 


F 


43 


M 


9 


M 


48 


M 


56 


M 


38 


M 


27 


M 


71 


M 


30 


M 


37 


M 


24 


F 


34 


M 


55 


M 


11 


M 


59 


M 


56 


M 


52 


F 


31 


M 


11 


M 


74 


M 


40 


F 


7 


M 


20 


M 


23 


M 


67 


M 


28 


M 


66 


F 


24 


M 


48 


M 


6 


F 


42 


F 


9 


M 


45 


M 


57 


M 


47 


M 


23 


M 


41 


M 


52 



mos. 
mos. 



Free Poliomyelitis 1 yr. 6 

Free Arthritis 1 yr. 3 

Free Abscess of arm 1 yr. 

Free Tuberculosis of hip and spine. ... 9 mos. 26 days 

Free Diabetes mellitus, tendoplasty. ... 9 mos. 11 days 

Free . . . . Cardiac decompensation 8 mos. 24 days 

Free Fracture and necrosis of right 

ulna 8 mos. 21 days 

Free Cardiac 8 mos. 19 days 

Free Carcinoma larynx 8 mos. 

Free Chronic arthritis 8 mos. 

Free Bronchiectasis, brachial palsy 7 mos. 9 days 

Free Ophthalmitis and keratitis 7 mos. 8 days 

Free Lung abscess . . ... 6 mos. 22 days 

Free Fracture left femur 6 mos. 18 days 

Free Osteomyelitis left tibia 6 mos. 8 days 

Free Cardiac . . 5 mos. 21 days 

Free Fracture left ulna and sprained 

left hip 5 mos. 22 days 

Free Chronic infectious arthritis 5 mos. 21 days 

Free , . Arthritis 5 mos. 13 days 

Free Cardiac 5 mos. 11 days 

Free Diabetic gangrene 5 mos. 2 days 

Free Acute arthritis . 5 mos. 

Free Gonorrheal vaginitis 4 mos. 22 days 

Free . . . Leprosy 4 mos. 19 days 

Free .Tuberculous foot 4 mos. 11 days 

Free Appendectomy hernia . . . . 4 mos. 11 days 

Free Brain tumor 3 mos. 24 days 

Free Myocarditis 3 mos. 22 days 

Free Hypertrophied tonsils and 

sprained right ankle 3 mos. 17 days 

Free Fracture . . 3 mos. 16 days 

Free Cardiac 3 mos. 12 days 

Free Malaria 3 mos. 10 days 

Free Second degree burns 3 mos. 7 days 

Free Psoriasis and lues 3 mos. 7 days 

Free Fractured femur 3 mos. 7 days 

Free Raynaud's disease 3 mos. 4 days 

Free Fractured vertebra 3 mos. 3 clays 

Free Anxiety neuroses 3 mos. 3 days 

Free Potts fracture 3 mos. 

1 !] Total, 39. 



Forms and Lists 



151 



University of California Hospital — 



M 


30 


M 


27 


M 


25 


F 


12 mos 


M 


28 


F 


7 


F 


44 


M 


54 


M 


40 


F 


6 



Free Berger's disease 6 mos. 16 days 

Free Fracture right femur 6 mos. 21 days 

Free Compound osteotomy of femur. . . 4 mos. 13 days 

$.50 daily Tumor left neck 4 mos. 

$1 daily Brain tumor 3 mos. 28 days 

$.50 daily Carditis old rheumatic fever 3 mos. 27 days 

Free Chronic endocervicitis 3 mos. 23 days 

Free Nephrectomy 3 mos. 16 days 

Free Teratoma 3 mos. 8 days 

Free Plastic for face burns 3 mos. 7 days 

Total, 10. 



In Privately Controlled Institutions 



Children's Hospital — 



M 


IV2 


M 


6]/ 2 


F 


4 


F 


7 


F 


10 


F 


8 


F 


7 


F 


7 


F 




M 




M 




M 


5 


M 


11 


F 


5 


M 


5 


F 


7 


F 


2 


M 


2 


M 


3 


F 


5 


F 


5 


F 


3 


F 


10 mos 


M 


10 mos 


M 


10 


M 


4 


M 


6y 2 


F 


8 mos 


F 


6 


F 


Adult 


M 


10 


M 


8 


M 


13 


M 


2 


F 


Adult 



Free Tuberculous hip (left) 6 yrs. 

Free Tuberculous fistulae of abdomen. . . 3 yrs. 

Free Tuberculous left hip 2 yrs. 

Free Birth injury spine 1 yr. 

Full Fracture left femur 1 yr. 

Free Tuberculosis left hip 1 yr. 

$50 mo Tuberculosis both hips 1 yr. 

Part pay Osteomyelitis of left knee 1 yr. 

$4 daily Multiple arthritis 1 yr. 

Part pay Tuberculous hips 1 yr. 

$25 mo Tuberculous hips 1 yr. 

$1 daily Tuberculous spine 1 yr. 

$20 mo Tuberculosis of left hip 1 yr. 

Free Tuberculosis of spine 1 yr. 

Full Pott's disease 1 yr. 

Full Congenital dislocation hips 11 mos. 

Free Cervical Pott's 10 mos. 

Free Post infantile paralysis 8 mos. 

Free Tuberculous hips 7 mos. 

Free Tibias orthopedic . 7 mos. 

Free Congenital hips 7 mos. 

Full Congenital hips . . 6 mos. 

Free Hair lip, cleft . palate 6 mos. 

Free Hair lip, cleft palate 6 mos. 

$5 weekly Osteomyelitis left large toe 6 mos. 

$1 daily Congenital hips 6 mos. 

$1 daily Diabetes mellitus 5 mos. 

Free Impetigo 5 mos. 

$20' mo Second degree burns 5 mos. 

$1 daily Fibroids in uterus adhesions. ..... 5 mos. 

$20 mo Post-infantile paralysis 4 mos. 

$15 mo Tuberculous spine 3 mos. 

$1 daily Club foot 3 mos. 

Free General streptococcus infection. . . 3 mos. 

Free Multiple arthritis 3 mos. 



6 mos. 

4 mos. 
8 mos. 
8 mos. 

7 mos. 

5 mos. 
5 mos. 

4 mos. 

5 mos. 
5 mos. 
5 mos. 
4 mos. 
2 mos. 
2 mos. 
1 mo. 

8 days 

4 days 
25 days 
19 days 
10 days 

5 days 
27 days 
25 days 
25 days 
16 days 

14 days 
25 days 

15 days 

9 days 

6 days 
27 days 
25 days 
23 days 

9 days 
8 days 



Total, 35. 



152 Hospital and Heai/th Survey 



Franklin Hospital- 



M 


33 


F 


52 


F 


89 


M 


• • 


M 


• • 


M 




M 


30 


F 




F 


50 


M 


80 


M 


82 


M 


64 


M 


52 


F 


53 


M 


26 



$20 weekly .... Pott's fracture 2 yrs. 6 mos. 

Free Total blindness 1 yr. 10 mos. 

Full Carcinoma uterus 1 yr. 1 mo. 

Member Senile decay 1 yr. 

Member Fracture femur 11 mos. 3 days 

Member Pernicious anemia 8 mos. 

$20 weekly .... Pott's fracture 8 mos. 

Member Fractured femur 6 mos. 8 days 

Full Spinal injury 6 mos. 8 days 

$20 weekly .... Compound fracture of leg 5 mos. 17 days 

Member Angina pectoris 4 mos. 21 days 

Member No diagnosis 4 mos. 

$20 up Spinal fracture 3 mos. 21 days 

Member Fracture femur 3 mos. 6 days 

$34.65 wk Compound fracture tibia and 

fibula; fracture radius and ulna.. 3 mos. 

Total, 15 



French Hospital- 



M 


55 


M 


21 


M 


40 


F 


78 


M 


59 


M 


43 


M 


40 


M 


64 


F 


78 


F 


48 


M 


30 


M 


22 



Free Paralysis 3 yrs. 1 mo. 



Free Tuberculous hip 

Free Tuberculosis 

Full Senility 

Free Osteomyelitis 

Free Osteomyelitis 

Free Luetic 

Free Chronic rheumatism 

Full Hemiplegia 

Free Hemiplegia I 

Free Osteomyelitis of right arm 4 mos. 6 days 

Full Malta fever 3 mos. 22 days 

Total, 12. 



yr. 11 mos. 

yr. 8 mos. 

yr. 5 mos. 

yr. 4 mos. 

yr. 2 mos. 

yr. 
yr. 

yr. 
mos. 



Lane and Stanford University Hospital- 



M 




M 


6 


F 


2 


M 




F 




M 




M 


37 


F 




M 


35 


M 




M 


35 



Full Complications 1 yr. 2 mos. 

Full Permanent trachetotomy tube 1 yr. 

Full Permanent trachetotomy tube 7 mos. 25 days 

Full Extraction of cataract of right 

eye 7 mos. 9 days 

Full Tonsillectomy and appendectomy . . 7 mos. 

Full Mental 6 mos. 25 days 

Full Paretic 6 mos. 12 days 

Full Arthritis 5 mos. 28 days 

Full Syphilis 4 mos. 14 days 

Full Paresis 3 mos. 10 days 

Full Infectious granuloma 3 mos. 2 days 

Total. 11. 



F 


64 


F 


64 


F 


50 


F 


75 


F 


75 


M 


4 


F 


68 


M 


37 


M 


27 


F 


33 


M 


77 


M 


S3 



Forms and Lists 153 



Mary's Help Hospital — 

Full . . Paralysis tongue 1 yr. 

$40 mo Paralysis 1 yr- 

Free Inoperable carcinoma 8 mos. 

Full • Senility 6 mos. 

Full Senility 5 mos. 12 days 

$17.50 mo No diagnosis 4 mos. 7 days 

Full Fractured hip 4 mos. 

Full Carcinoma 4 mos. 

Full Infected arm . . .' 4 mos. 

Two-thirds . . . Heart 4 mos. 

Full Prostate gland, etc 3 mos. 

Full Fractured leg 3 mos. 

Total, 12. 



Mount Zion Hospital — 

M . . Full Enlarged prostate 1 yr. 5 mos. 

M .. Full Transverse fracture lower and 

middle third femur 9 mos. 24 days 

M 37 Full Cardiac decompensation 6 mos. 7 days 

F 20 Full Acute diffuse lupus erythema- 
tosus 3 mos. 28 days 

M 55 $10 weekly. . . .Gastric carcinoma 3 mos. 12 days 

Total, 5. 



St. Luke's Hospital — 

Full Amebiasis and appendicitis 1 yr. 1 mo. 

Full Amebiasis 6 mos. 27 days 

Full Fractured leg 5 mos. 24 days 

Full Carcinoma breast 5 mos. 7 days 

Full Contracture of hand 5 mos. 2 days 

Full Feeding 4 mos. 28 days 

Full Appendicitis 3 mos. 19 days 

Full Fracture leg 3 mos. 11 days 

Full Tuberculous spine 3 mos. 7 days 

Full Ankylosed knee 3 mos. 6 days 

Total, 10. 



F 


32 


F 


38 


M 


40 


F 


43 


M 


44 


F 




M 


32 


M 


40 


F 


• • 


F 


26 



154 Hospital and Health Survey 



St. Mam '> l [ospital — 

Free Arthritis 14 yrs. 10 mos." 

Free Severed spinal cord 10 yrs. 3 mos. 

Free Paralysis 6 yrs. 7, mos. 

Free Arthritis 3 yrs. 6 mos. 

Free Skin grafting — burns 2 yrs. 11 mos. 

Approximately Arthritis 2 yrs. 5 mos. 

75c daily, private 

room when possible. 

Full Severed spinal cord 1 yr. 5 mos. 

Full Fracture back 1 yr. 3 mos. 

Full Carcinoma of breast 10 mos. 28 days 

Full Cerebral hemorrhage 5 mos. 5 days 

$3.65, private room Arthritis 5 mos. 

and 2/3 of extras. 

Full Excision portion seventh rib 5 mos. 

Full Carcinoma of breast 4 mos. 26 days 

Full Osteomyelitis of right tibia 4 mos. 24 days 

Free Chronic myocarditis 4 mos. 11 days 

Full Fracture right femur 4 mos. 3 days 

Full Osteomyelitis of femur 3 mos. 15 days 

Full Myocarditis 3 mos. 15 days 

Full Fracture tibia and fibula 3 mos. 11 days 

Full Fracture right leg 3 mos. 4 days 

Total, 20 



M 




F 


# 


M 


t # 


F 


60 


M 




F 


55 


M 


27 


M 


46 


F 




F 


45 


M 




F 


49 


F 


46 


M 


27 


F 


65 


M 


27 


M 


54 


F 


86 


M 


40 


F 


80